CHAPTER 43: Surgeries for Benign Gynecologic Disorders

Abdominal entry is the first step for many gynecologic surgeries. Either vertical or transverse incisions may be used, and each offers particular advantages. Vertical incisions may be midline or paramedian, but of the two, the midline is chosen more often. This incision offers quick entry, minimal blood loss, superior access to the upper abdomen, generous operating room, and the flexibility for easy wound extension if greater space or access is needed. No important neurovascular structures traverse this incision. Thus, it may be favored for patients using anticoagulation agents. Despite advantages, midline incisions are more frequently associated with greater postoperative pain, poorer cosmetic results, and increased risks of wound dehiscence or incisional hernia compared with low transverse incisions. Last, for those with prior laparotomy, the incision type is typically repeated for subsequent surgeries.

PREOPERATIVE

Consent

For abdominal entry, patients are informed of wound infection or dehiscence risks. Additionally, the chance of bowel or bladder injury is present with any abdominal entry, especially when extensive adhesions are encountered.

Prophylaxis

Laparotomy per se does not require antibiotic prophylaxis or bowel preparation. These are dictated by the planned procedure. Prevention for venous thromboembolism is warranted, and options are described in Chapter 39.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

After administration of adequate regional or general anesthesia, the patient is positioned supine. If needed, hair in the path of the planned incision is clipped; a Foley catheter is placed; and abdominal preparation is completed.

Skin and Subcutaneous Layer

The skin is incised vertically in the midline beginning 2 to 3 cm above the symphysis pubis and extending cephalad to within 2 cm of the umbilicus. If less space is required, this incision may be shortened. For greater space or access, the incision may arch around the umbilicus and then continue cephalad in the upper abdominal midline. This extension passes to the left of the umbilicus to avert transection of the ligamentum teres. This remnant of the umbilical vein courses in the free border of the falciform ligament. The umbilicus itself contains attenuated fascia. Thus, the periumbilical incision should arch laterally enough to provide quality fascia on either side of the incision to allow an ultimately secure closure.

The subcutaneous layers of Camper and Scarpa are then incised either sharply with long even strokes or with electrosurgical blade to reach the linea alba fascia. Ideally, the number of blade strokes is minimized to avoid hatch marking the tissue, which increases tissue damage and wound infection risks.

Fascia

Tendinous fibers from the anterior abdominal wall aponeuroses merge in the midline of the abdomen to form the linea alba. This fascia layer is sharply entered near the midpoint of the incision (Fig. 43-1.1). This incision is extended first cephalad and then caudally to mirror the length of the skin incision. To minimize injury to viscera during this extension, the linea alba is elevated by index fingers of the surgeon and assistant or by the open tips of a pean clamp (Fig. 43-1.2).

Once the fascia is incised, the right and left rectus abdominis muscle bellies are bluntly separated laterally. Inferiorly, sharp incision may be required to complete this. To avert injury to organs below, the rectus muscles are elevated during this division. Each half of the pyramidalis muscle lies atop its respective rectus belly, and this muscle is similarly divided sharply at the midline.

Peritoneum

For entry, the peritoneum is identified between the rectus abdominis muscle bellies. It is grasped with two hemostats in the upper portion of the incision to avoid cystotomy. The interposed peritoneum should be palpated or visually examined to exclude intervening viscera. Only then is it sharply cut (Fig. 43-1.3). Next, an index finger sweeps directly beneath it to identify adhered bowel or omentum. If free, the peritoneum is elevated by fingers of the surgeon and assistant to protect viscera beneath. As the incision is extended cephalad above the arcuate line, the transverse fibers of the posterior rectus sheath are seen and are cut along with the peritoneum. As the incision is extended caudally, the transversalis fascia is found superficial to the peritoneum. To prevent bladder dome injury, this thin fascia layer is elevated by insinuating fingers beneath it and is cut, with the incision extending caudally. Next, the peritoneum beneath the transversalis fascia is similarly incised (Fig. 43-1.4). The bladder dome is identified by increasing tissue vascularity and thickness. Of note, the urachus, which is the remnant of the allantois, may be seen as a white cord extending from the bladder dome toward the umbilicus in the midline.

During abdominal entry, prior surgery may blur clear tissue planes. For example, the true midline may be deviated laterally, and after fascial incision, only rectus fibers may be seen. To find the midline after incising the fascia, fibers of the pyramidalis muscles can be followed as they angle toward the midline. Also, visually recreating a line between the symphysis and umbilicus can aid orientation. To reach the midline, the fascia closest to the presumed midline is grasped both cephalad and caudad along its length with Kocher clamps to create upward tension (Fig. 43-1.5). Simultaneously, downward manual pressure atop the ipsilateral rectus belly accentuates fibers between the fascia and underlying rectus belly. These fibers are then cut to permit lateral dissection of the fascia away from the rectus belly. This is continued laterally until the midline is identified. If the midline is not identified after some dissection on one side, the same steps can be repeated on opposite side.

Also with prior surgery, planes between the fascia, peritoneum, and viscera may be poorly defined. In these cases, a gradual layered entry is required to avoid organ injury. One technique uses Metzenbaum scissors. Scissor tips are insinuated between tissue layers such that the tips are seen each time prior to cutting. This minimizes the risk that the thicker bowel or bladder wall will be cut. If adhesions are found, they are divided. Dissection is maintained close to the fascial or peritoneal edge to minimize visceral injury.

Operative Field

After abdominal entry, a self-retaining retractor is commonly placed to retract the bowel, omentum, and abdominal wall muscles. Moist laparotomy sponges are placed around the bulk of bowel and gently directed cephalad. Adhesiolysis may be required to adequately free intestines for this repositioning. Upper blades of the retractor assist in holding these loops up and away from the pelvis and operating field. The shortest blades possible are preferred for lateral retraction. This reduces the risk of femoral or genitofemoral nerve compression by a blade resting atop the psoas major muscle. Once pelvic organs are adequately exposed, the planned abdominal surgery can proceed.

Wound Closure

Closure of the visceral or parietal peritoneum is not required and is individualized (Chap. 40). Starting from each end of the incision, the fascia is closed to its midpoint using a continuous running suture with a 0-gauge delayed-absorbable suture. These sutures are then tied together. If the subcutaneous layer measures less than 2 cm, then no closure is typically necessary. For deeper wounds, interrupted stitches of 2-0 to 4-0 gauge absorbable or delayed-absorbable suture are used to close this layer. The skin is closed with a subcuticular stitch using 4-0 gauge delayed-absorbable suture, staples, or other suitable method (Chap. 40).

POSTOPERATIVE

For most gynecologic surgeries, recovery from the abdominal incision constitutes the greatest portion of postsurgical healing. Midline incisions lead to significant pain during ambulation, coughing, and deep breathing. As a result, women undergoing laparotomy are at greater risk of postoperative thrombotic and pulmonary complications. Prevention of these is warranted and described in Chapter 42. In addition, return of normal bowel function is commonly slowed, and signs of ileus should be monitored. Hospitalization typically varies from 1 to 3 days, and return of normal bowel function usually dictates this course. Postoperative activity in general can be individualized, although vigorous abdominal exercise is delayed for 6 weeks to allow for fascial healing. Driving can be resumed when pain does not limit the ability to brake quickly and when narcotic medications are not in use. Return to work is variable, although 6 weeks is commonly cited.

The Pfannenstiel, Cherney, and Maylard incisions are transverse abdominal incisions used for gynecologic procedures. Of these, the Pfannenstiel incision is the most commonly used incision for laparotomy in the United States. Because the transverse incision follows Langer lines of skin tension, excellent cosmetic results can be achieved. Additionally, decreased rates of postoperative pain, fascial wound dehiscence, and incisional hernia are noted. Use of the Pfannenstiel incision, however, is often discouraged for cases in which greater operating space or upper abdominal access is anticipated. Last, because of the layers created by incision of the internal and external oblique aponeuroses, purulent fluid can collect between these. Therefore, cases involving abscess or peritonitis favor use of a midline incision, which divides the fused linea alba.

PREOPERATIVE

Consent

General risks associated with transverse laparotomy incisions are similar to those for vertical incisions. Transverse incisions, however, carry risk of injury to the iliohypogastric and ilioinguinal nerves. These injuries frequently involve only transient sensory loss but rarely may lead to debilitating, chronic neuropathic pain.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

After administration of adequate regional or general anesthesia, the patient is positioned supine. If needed, hair in the path of the planned incision is clipped; a Foley catheter is placed; and abdominal preparation is completed.

Skin and Subcutaneous Layer

Two to 3 cm above the symphysis pubis, an 8- to 10-cm transverse incision is made with its lateral margins arching slightly cephalad. If less space is required, this length can be shortened. The incision is deepened sharply with scalpel or electrosurgical blade until the anterior rectus sheath is reached. The superficial epigastric vessels typically lie several centimeters from the midline and halfway between the skin and fascia. Coagulation of these vessels will limit incisional blood loss.

Fascia

The anterior rectus sheath is sharply incised transversely in the midline (Fig. 43-2.1). At the level of the incision, the anterior rectus sheath is composed of two visible layers, the aponeuroses from the external oblique muscle and a fused layer containing aponeuroses of the internal oblique and transversus abdominis muscles. Lateral extension of the anterior rectus sheath incision requires cutting each layer individually (Fig. 43-2.2). This permits identification and ideally, avoidance of the iliohypogastric and ilioinguinal nerves as they run between these two fascial layers.

Of note, at the level of the incision, the inferior epigastric vessels typically lie outside the lateral border of the rectus abdominis muscle and beneath the fused aponeuroses of the internal oblique and transversus abdominis muscles. Thus, lengthening the incision farther laterally may cut these vessels. If significant lateral extension is required, these vessels are identified, clamped, and ligated. This prevents bleeding and vessel retraction with later hemorrhage. In addition, risk of iliohypogastric and ilioinguinal nerve injury also increases as the incision is carried lateral to the rectus abdominis muscle borders (Rahn, 2010).

The superior edge of the fascial incision is grasped with a Kocher clamp on either side of the midline. Traction is directed cephalad and slightly outward. In the area superior to the initial incision, the anterior rectus sheath is then bluntly or sharply separated from the underlying rectus abdominis muscle (Fig. 43-2.3). With blunt dissection, upward facing fingers first push cephalad and then roll to direct pressure laterally. The fascia separates easily from the bellies of the rectus muscle, but it may be densely adhered along the midline and require sharp dissection (Fig. 43-2.4). Several small perforating nerves and vessels traverse the space between the anterior rectus sheath and rectus muscle. These vessels are coagulated to avoid laceration and bleeding. Upon completion of this dissection, a semicircular area with a radius of 6 to 8 cm has been created. A similar separation is performed in the area inferior to the initial fascial incision.

The rectus abdominis muscle bellies are then separated laterally from the midline either bluntly or sharply. The pyramidalis muscle, located superficial to the rectus muscle, usually requires sharp division at the midline.

Peritoneum

Peritoneal entry is fully described and illustrated in Section 43-1, Steps 3 and 4. To summarize, upon separation of the rectus muscle bellies, the thin, filmy peritoneum is identified, grasped with two hemostats, and sharply incised. The peritoneal incision is then extended superiorly and inferiorly. Once the abdominal cavity has been entered and clear visualization established, the surgeon can proceed with the planned operation.

Wound Closure

Closure of the visceral or parietal peritoneum is not required and is individualized. Starting from each end of the incision, the fascia is closed to its midpoint using a continuous running suture line with a 0-gauge delayed-absorbable suture (Fig. 43-2.5). These strands are then tied together. The subcutaneous layer and skin are closed similar to the midline vertical incision (Section 43-1).

POSTOPERATIVE

The postoperative course for low transverse incisions follows that described for midline incisions.

The Cherney incision is a transverse abdominal incision that is similar to the Pfannenstiel incision in its early steps. After the anterior rectus sheath is opened, however, the tendons of the rectus abdominis and pyramidalis muscles are transected 1 to 2 cm above their insertion into the symphysis pubis. These muscles are then lifted cephalad to provide access to the peritoneum. At this level, the inferior epigastric vessels run well lateral to the rectus bellies and typically are spared. However, if additional lateral extension is required, these vessels are ligated and transected.

This incision offers generous operating space and access to the space of Retzius. Thus, it may be a primary choice when these requirements are anticipated. Additionally, Pfannenstiel incisions may be converted to Cherney incisions when an unexpected need for additional space arises.

PREOPERATIVE

Preparation and consenting prior to Cherney incision are similar to that for Pfannenstiel incision.

INTRAOPERATIVE

Surgical Steps

Initial Steps

The initial steps mirror that of the Pfannenstiel incision (Steps 1-3). Thus, the skin is incised transversely beginning 2 to 3 cm above the symphysis, the fascia is divided transversely, and the rectus sheath is dissected off the rectus abdominis muscle bellies. After these steps, however, the techniques diverge.

Fascia

The fascial opening reveals the rectus abdominis and pyramidalis muscles. Cephalad to the symphysis pubis, fingers are insinuated beneath the rectus muscle tendons. This blunt dissection begins laterally and extends toward the midline. During insinuation, fingers exert pressure dorsally and against the bladder to protect it during tendon division. After this, fingers lift up the muscle tendons, which are then transected 1 to 2 cm above the symphysis pubis (Fig. 43-3.1). The muscles are flipped up and cephalad.

The peritoneum is grasped with two hemostats at a level above the bladder dome and is sharply incised. This incision is extended laterally. Once the abdominal cavity has been accessed, the planned surgery can proceed. Importantly, the risk of injury, particularly to the femoral and genitofemoral nerves, is increased when self-retaining retractors are used with this generally wider incision. This is also true for the Maylard incision. Thus, lateral retractor blades should fit just under the edges of the incision and not rest atop the psoas muscle.

Wound Closure

During wound closure, the cut ends of the rectus muscle tendons are affixed with interrupted sutures of 0-gauge delayed-absorbable sutures to the undersurface of the inferior fascial edge (Fig. 43-3.2). To avoid osteitis pubis or osteomyelitis, the tendons should not be affixed directly to the symphysis pubis.

Starting from each end of the incision, the fascia is closed to its midpoint using a continuous running suture with a 0-gauge delayed-absorbable suture. These strands are then tied together. The subcutaneous layer and skin are closed as with the midline vertical incision.

POSTOPERATIVE

The postoperative course for low transverse incisions follows that described for midline incisions.

The Maylard incision differs mainly from the Pfannenstiel incision in that the rectus sheath is not dissected away from the rectus abdominis muscle and that the bellies of the rectus abdominis muscle are transected. Transection affords extensive access to the pelvis. However, it is technically more difficult due to its required isolation and ligation of the inferior epigastric vessels. Moreover, the Maylard incision has been used infrequently because of concerns regarding greater postoperative pain, decreased abdominal wall strength, longer operating times, and increased febrile morbidity. Randomized studies, however, have not supported these concerns (Ghanbari, 2009; Mathai, 2013). The Maylard incision should be avoided in those patients in whom the superior epigastric vessels have been interrupted, as this leaves the rectus abdominis muscles with inadequate blood supply. Also, patients with significant peripheral vascular disease may rely on the inferior epigastric vessels for collateral blood supply to their lower extremities (Salom, 2007).

PREOPERATIVE

Preparation and consenting prior to Maylard incision are similar to that for Pfannenstiel incision.

INTRAOPERATIVE

Surgical Steps

Initial Steps

The initial steps mirror that of the Pfannenstiel incision (Steps 1 and 2). Thus, the skin is incised transversely beginning 2 to 3 cm above the symphysis, and the fascia is divided transversely. After these steps, the techniques diverge, and in contrast to the Pfannenstiel incision, the anterior rectus sheath is not dissected away from the underlying rectus muscle.

The inferior epigastric vessels lie posterolateral to the rectus abdominis muscle bellies. Bilaterally, these vessels are identified, ligated, and transected. This step avoids their laceration and hemorrhage when the rectus abdominis muscle is transected.

Rectus Abdominis Muscle

With fingers, the rectus abdominis muscle is bluntly dissected away from the underlying transversalis fascia and peritoneum. These latter are the encountered layers because the posterior rectus sheath ends at the arcuate line and is absent caudal to this line. The surgeon’s fingers are slid behind the rectus muscle bellies, and this muscle is then transected using an electrosurgical blade (Fig. 43-4.1).

Peritoneum

With two hemostats, the peritoneum is grasped, and it is sharply incised above the level of the bladder dome. This incision is then extended laterally (Fig. 43-4.2). After access is obtained to the abdominal cavity, planned surgery can proceed. As with Cherney incisions, careful self-retaining retractor placement is necessary to lessen the risk of femoral or genitofemoral nerve injury.

Wound Closure

At incision closure, the fascia is closed with a running stitch using 0-gauge delayed-absorbable suture. Closing the fascia adequately reapproximates the transected muscle fibers, and therefore the divided muscle bellies are not directly sutured together. Starting from each end of the incision, the fascia is closed to its midpoint using a continuous running suture line with a 0-gauge delayed-absorbable suture. These strands are then tied together. The subcutaneous layer and skin are closed as with the midline vertical incision.

POSTOPERATIVE

The postoperative course for low transverse incisions follows that described for midline incisions.

Ovarian cyst excision is typically prompted by patient symptoms or by ovarian qualities that suggest a lower concern for ovarian malignancy (Chap. 9). Removal of the cyst alone can offer those with ovarian pathology an opportunity to preserve hormonal function and reproductive capacity. Accordingly, ovarian cystectomy goals include gentle tissue handling to limit postoperative adhesions and reconstruction of normal ovarian anatomy to aid the later transfer of ova to the fallopian tube.

In some women, a cystectomy may be performed laparoscopically rather than with laparotomy. Several studies support the safe and effective use of laparoscopy for this purpose (Chap. 9). That said, there are settings in which its role is limited. In general, if a cyst is large, adhesive disease limits access and mobility, or the risk of malignancy is greater, then laparotomy is preferred.

PREOPERATIVE

Consent

In addition to general surgical risks of laparotomy, the major risk of cystectomy is extensive bleeding from or injury to the ovary that, in turn, necessitates removal of the entire ovary. Also, a variable degree of ovarian reserve may be lost with ovarian cystectomy. If ovarian cancer is suspected prior to surgery, patients should be educated regarding the possibility of surgical staging, including the need for hysterectomy and removal of both ovaries (Chap. 35).

Many patients undergoing cystectomy for ovarian pathology have associated pain. Although in most cases cystectomy will be curative, in other instances, pain may persist despite cyst excision. This is especially true in those with coexistent endometriosis. Thus, patients are counseled that cystectomy may not relieve chronic pain in all cases.

Patient Preparation

Bowel preparation and antibiotics are typically not required preoperatively. If hysterectomy is required during ovarian staging, antibiotics may be given intraoperatively. Laparotomy dictates venous thromboembolism prophylaxis, and options are found in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Because of the potential for cancer staging in the upper abdomen if malignancy is found, general anesthesia is typically indicated for this inpatient procedure. The patient is supine. After anesthesia induction, hair in the planned incision path is clipped if needed; a Foley catheter is inserted; and abdominal preparation is completed. Because hysterectomy may be needed if malignancy is found, the vagina is also surgically prepared.

Abdominal Entry

Most ovarian cysts can be removed through a Pfannenstiel incision. Extremely large cysts or those with a greater concern for malignancy usually require a vertical incision. This latter incision provides generous operating space and adequate upper abdomen access for cancer staging.

As described in Chapter 35, cell washings from the pelvis and upper abdomen are collected prior to ovarian manipulation and are saved if a cancer is found. The upper abdomen and pelvis are explored, and excrescences or suspicious areas are sampled and sent for intraoperative frozen-section analysis.

A self-retaining retractor is placed within the incision, and the bowel and omentum are packed from the operating field. The ovary is brought into view, and moist laparotomy sponges are placed in the cul-de-sac and beneath the ovary. This helps to minimize contamination of the pelvis if the cyst ruptures during excision.

Ovarian Incision

The ovary is held between the surgeon’s thumb and opposing fingers. The ovarian capsule that overlies the dome of the cyst is then cut with either scalpel or electrosurgical needle tip. This incision is ideally placed on the antimesenteric surface of the ovary to minimize dissection into vessels at the ovarian hilum. The incision is ideally deepened to reach the cyst wall without entering and rupturing the cyst (Fig. 43-5.1). Allis clamps are then placed on the incised edges of the ovarian capsule to aid traction and countertraction during dissection.

Cyst Dissection

Blunt dissection with fingertip or knife handle or sharp dissection with Metzenbaum scissor tips is used to develop the cleavage plane between the cyst wall and the remaining ovarian stroma (Fig. 43-5.2). If adhesions obliterate the cleavage plane, sharp dissection is preferred. As an assistant gently pulls the Allis clamps in a direction away from the cyst wall, the surgeon places fingers proximate to the advancing cleavage plane and pulls the cyst in the direction opposite the Allis clamps. Such traction and countertraction across the cleavage plane aid dissection. Because the surface of the cyst wall is often smooth and slippery, the surgeon may place an unfolded thin gauze sponge between fingers and the cyst wall to afford a better grip.

As dissection approaches completion, the highly vascular ovarian hilum is reached. If possible, a hemostat or pean clamp is placed across the small remaining tissue bridge between the cyst and normal ovary. The clamp is positioned closer to the ovary to allow space for scissors to cut the tissue pedicle and free the cyst without rupture. The pedicle is suture ligated with a fine absorbable suture. The ovarian bed is then examined, and bleeding points are coagulated or ligated.

Cyst Excision

Once the cyst is removed, it may be sent to the pathology department for intraoperative frozen-section analysis. In benign cases, excess capsule can be sharply trimmed from ovaries in which large cysts have stretched and thinned the ovarian surface. This excision is performed to help restore normal ovarian anatomy. But because ovarian follicles are contained within even extremely thinned capsules, this tissue is preserved whenever possible.

Ovarian Closure

The ovarian bed is then closed in layers using 3-0 or 4-0 gauge delayed-absorbable suture. These sutures reapproximate the ovarian tissue that previously surrounded the cyst on both sides (Fig. 43-5.3). With a thinned ovarian cortex, the needle tip should not be driven through the capsule. Exposed suture on the ovarian surface may increase adhesion formation. The ovarian incision is closed with a running subcortical stitch (similar to subcuticular stitch) using 5-0 gauge delayed-absorbable suture.

Incision Closure

Laparotomy sponges are removed from the cul-de-sac, and the pelvis is copiously irrigated with an isotonic solution such as lactated Ringer solution. Irrigation assumes an even greater importance with ovarian cyst rupture. For example, spill from a mature cystic teratoma (dermoid), if neglected, may induce a chemical peritonitis. Depending on the surgeon’s preference and the patient’s anatomy, an adhesion barrier may be placed around the ovary (Chap. 11). The remaining packs and retractor are removed, and the abdominal incision is closed.

POSTOPERATIVE

After surgery, patient care in general follows that described for laparotomy.

Removal of the ovary and fallopian tube is more commonly performed by laparoscopy. However, laparotomy is typically indicated if the potential for malignancy is great, if the ovary is larger than 8 to 10 cm, or if extensive adhesions are anticipated. With either approach, the essential steps of salpingo-oophorectomy (SO) are: preventive identification of the ipsilateral ureter, infundibulopelvic (IP) ligament ligation, combined ligation of the proximal fallopian tube and uteroovarian ligament, and transection of the intervening mesovarium and mesosalpinx. Indications are varied and include suspicion for ovarian malignancy, ovarian cancer prevention for at-risk women, large symptomatic ovarian cysts in postreproductive females, and for reproductive-aged women, large, symptomatic ovarian cysts that are not suitable for cystectomy.

PREOPERATIVE

Patient Evaluation

This surgery is typically performed to remove ovarian pathology that has been evaluated sonographically. If anatomy is unclear, magnetic resonance (MR) imaging may add information. As listed in Chapters 35 and 36, tumor markers are selectively drawn prior to surgery if malignancy is suspected.

Consent

In general, serious complications with SO are infrequent but include organ injury, especially to the ureter; hemorrhage; wound infection or dehiscence; and anesthesia complications. Ovarian pathology is the most common indication for SO. Thus, the possibility of cancer staging and a description of its steps are explained. Moreover, malignant cyst rupture and spillage are risks, and patients are informed that this will advance the cancer stage (Chap. 35). Many women undergoing SO for ovarian pathology have associated pain. Although removal of the ovary in most cases will be curative, in other instances, pain may persist despite SO. Last, if performed bilaterally, SO dramatically curtails estrogen production. Thus, a preoperative discussion of consequences, as outlined on page 951, is recommended.

Patient Preparation

Bowel preparation and antibiotics are typically not required preoperatively. If hysterectomy is required during ovarian staging, antibiotics may be given intraoperatively. Laparotomy dictates venous thromboembolism prophylaxis, and options are found in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Salpingo-oophorectomy performed via laparotomy typically requires general anesthesia to allow staging of the upper abdomen if malignancy is found. The patient is supine. After anesthesia induction, hair in the planned incision path is clipped if needed; a Foley catheter is inserted; and abdominal preparation is completed. Because of a possible need for hysterectomy if malignancy is found, the vagina is also surgically prepared.

Abdominal Entry

Either a transverse or vertical incision may be used for SO. Clinical factors such as ovarian size and risk of malignancy influence this selection, as discussed on page 926.

Following abdominal entry, cell washings from the pelvis and upper abdomen are collected prior to ovarian manipulation. These are sent for pathologic evaluation if cancer is found. The upper abdomen and pelvis are explored. Peritoneal or omental implants are sampled and sent for intraoperative frozen-section analysis.

Exposure

A self-retaining retractor such as an O’Connor O’Sullivan or Balfour re­tractor is placed, and the bowel is packed from the operating field. The affected adnexa is grasped and elevated from the pelvis. If extensive adhesions are found, normal anatomic relationships are restored.

Ureter Location

Because of its close proximity to the IP ligament, the ureter is identified prior to clamp placement. In many instances, the ureter is seen beneath the posterior pelvic sidewall peritoneum. Here, it can often be identified as it enters the pelvis and crosses over the common iliac artery bifurcation just medial to the ovarian vessels. In other cases, retroperitoneal isolation of the ureter is required. For this, the peritoneum within the area bounded by the round and IP ligaments and the external iliac vessels is tented with tissue forceps and incised. This first peritoneal incision is extended cephalad toward the pelvic brim (Fig. 43-6.1). The incision also later assists in isolating the IP ligament for ligation. Once this peritoneal window is open, blunt dissection is directed deep, cephalad, and slightly medially through gauzy areolar connective tissue (see Step 6 of abdominal hysterectomy). The ureter is typically found attached to the medial leaf of the incised peritoneum.

Infundibulopelvic Ligament

The adnexa is lifted from the pelvis and inspected. To isolate the IP ligament, a second peritoneal opening is sharply created with Metzenbaum scissors or electrosurgical blade. It is made in the posterior leaf of the broad ligament below the IP ligament but above the ureter. This incision is extended medially beneath the fallopian tube and uteroovarian ligament and toward the uterus. While remaining parallel to the IP ligament, it is also extended lateral and cephalad towards the pelvic brim. Ideally, the ureter is in view during this entire incision.

As a result of both peritoneal incisions, the IP ligament is isolated. This vascular ligament is then clamped with a Heaney or other sturdy clamp, and the clamp curve faces upward (Fig. 43-6.2). Of note, if SO is performed for cancer risk reduction, the clamp is brought across the IP close to the sidewall. A single Kelly (pean) clamp is placed across the IP at a distance medial to the Heaney clamp. During completion of adnexectomy, this medial clamp prevents “back-bleeding” and is removed with the specimen.

As shown, the ligament is transected between the Heaney and Kelly clamps. To ligate the IP pedicle, a free tie of 0-gauge delayed-absorbable suture is placed around the Heaney clamp. As the knot is secured, this clamp is opened and closed quickly, that is, “flashed.” Next, a transfixing suture is placed around the Heaney clamp (Fig. 40-22). This suture is placed below the clamp yet distal to the first free tie to avoid hematoma formation by needle puncture of ovarian vessels. As this knot is cinched in place, the Heaney clamp is removed.

Fallopian Tube and Uteroovarian Ligament

With the adnexa elevated, a Heaney or similar clamp is placed across both the proximal uteroovarian ligament and fallopian tube. It also incorporates some of the mesosalpinx and mesovarium. The clamp’s curve faces the ovary. Next, another clamp enters laterally and is directed medially to close around the remaining mesosalpinx and mesovarium beneath the ovary (Fig. 43-6.3). Again, the clamp curve faces the ovary. Ideally, the tips of both clamps touch beneath the adnexa. Above both of these clamps are stacked second clamps, which lie a distance above their partners and closer to the ovary. Tissue between the stacked clamps is cut with curved Mayo scissors to free the adnexa.

The freed adnexa is removed from the operative site and sent to pathology for evaluation. If malignancy is suspected, an intraoperative frozen section is requested. Tissue within each of the remaining two clamps is individually suture ligated with 0-gauge delayed-absorbable suture.

Wound Closure

The retractor and packing sponges are removed from the abdomen. The abdominal incision is then closed as described for vertical or Pfannenstiel incisions.

POSTOPERATIVE

Patient recovery is similar to that described for laparotomy. In reproductive-aged women, if only one ovary is removed, hormonal and reproductive function is preserved. However, if both are excised, then surgical menopause follows, and hormone replacement is considered (Chap. 22).

Interval partial salpingectomy is similar to puerperal midsegment salpingectomy and differs mainly in procedure timing and in abdominal entry. In contrast to postpartum or postabortal sterilization, the term interval designates performance unrelated in time to pregnancy. Accordingly, for most women undergoing interval sterilization, the uterus is small and lies within the confines of the pelvis. Thus, fallopian tubes are reached either laparoscopically or through a low transverse incision.

In general with interval partial salpingectomy, a midtubal segment of fallopian tube is excised, and the severed ends seal by fibrosis and reperitonealization. Commonly used methods of interval sterilization include the Parkland and Pomeroy techniques.

Of tubal sterilization methods, interval partial salpingectomy is infrequently selected for U.S. women who elect sterilization (Peterson, 1996). More commonly, laparoscopic techniques are employed, mainly because of laparoscopy’s postsurgical advantages (Chap. 41). Accordingly, interval partial salpingectomy is typically selected for cases in which laparoscopy may not be indicated. Examples include cases complicated by extensive adhesions, those in which other concurrent pelvic pathology dictates laparotomy, or those in which laparoscopic equipment or surgical skills are lacking. Moreover, new recommendations advocate for risk reducing total salpingectomy when feasible as described on page 939. Thus, the opportunities for laparotomic interval salpingectomy may be few.

PREOPERATIVE

Patient Evaluation

As with any sterilization procedure, pregnancy should be excluded prior to the procedure by means of either urine or serum β-human chorionic gonadotropin (hCG) testing. Similarly, to limit the possibility of an early, undetected luteal-phase conceptus, sterilization is ideally performed during the follicular phase of the menstrual cycle, and an effective contraceptive method is used until surgery.

Consent

Partial salpingectomy is an effective method of sterilization. Pregnancy rates of less than 2 percent are typical. Failures may result from tubal recanalization or technical errors, such as ligation of the wrong structure.

Tubal sterilization is a safe surgical procedure, and complication rates are below 2 percent (Pati, 2000). Of these, anesthesia complications, organ injury, and wound infection are the most frequent. In addition, although pregnancy is uncommon following sterilization, when pregnancy does occur, the risk of ectopic pregnancy is high and approximates 30 percent (Peterson, 1996; Ryder, 1999). However, because tubal sterilization is highly effective contraception, the overall risk of pregnancy is low, and therefore also is the risk of ectopic pregnancy.

Aside from physical risks, some women experience regret following sterilization. Rates are highest in those 30 years or younger (Curtis, 2006; Hillis, 1999). Accordingly, prior to surgery women are counseled regarding the risk of regret, the permanence of the procedure, and alternative effective long-term contraceptive methods (American College of Obstetricians and Gynecologists, 2011).

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Interval partial salpingectomy is usually an outpatient procedure, performed under general or regional anesthesia. Following administration of anesthesia, the patient is placed supine, the abdomen surgically prepared, and the bladder drained.

Minilaparotomy

For most patients, a 4- to 6-cm transverse Pfannenstiel incision is sufficient. Small Richardson or army-navy retractors provide adequate intraabdominal visualization in most cases. A vaginally placed sponge stick or uterine manipulator can elevate the uterus to help bring fallopian tubes into view.

Tubal Identification

A common reason for sterilization failure is ligation of the wrong structure, usually the round ligament. Identification and isolation of the fallopian tube prior to ligation and submission of tubal segments for pathologic confirmation is therefore required. In some cases, especially those with associated tubal adhesions, this step may be challenging. Lateral extension of the incision may be needed for improved exposure.

Initially, the uterine fundus is identified. At the cornu, insertion of the fallopian tube lies posterior to that of the round ligament, and this orientation can initially guide the surgeon to the correct structure. A primary Babcock clamp is used to elevate the fallopian tube proximally, while a second clamp grasps the tube more distally. The primary clamp is then moved again and is placed distal to the second. The second is then removed and again placed distal to the first. In this manner, the surgeon “marches” down the length of the tube to reach the ampulla and identify fimbria.

Parkland Method

At the midpoint of the fallopian tube, an avascular space in the mesosalpinx is identified, and a hemostat is placed directly beneath the tube. The selected site should allow excision of a 2-cm tubal segment that does not incorporate the fimbria. Ligation of the fimbrial portion leads to a greater risk of tubal recanalization and higher failure rates.

The hemostat is bluntly advanced through the mesosalpinx as counterpressure is applied with the index finger. Once advanced through the defect, the hemostat tips are gently opened to expand the aperture (Fig. 43-7.1). The end of a 0-gauge chromic free tie is placed in the tip of the hemostat and pulled through the opening. This is repeated, bringing another tie through the rent. The midsegment is lifted, and the distal suture tied. The second tie is then secured around the proximal fallopian tube.

Tubal Excision

The Metzenbaum scissor tips are inserted through the mesosalpingeal defect, and the proximal portion of the fallopian tube is cut. A 0.5-cm pedicle is left to ensure that the tube will not slip through its ligature (Fig. 43-7.2). The tube is sharply dissected from the mesosalpinx toward the distal ligature, thereby freeing the tubal segment from the mesosalpinx. The distal part of the segment is excised to leave a 0.5-cm pedicle, and an adequate 2-cm tubal segment is obtained. The pedicles and mesosalpinx are inspected for hemostasis. The procedure is then repeated on the other side. Tubal segments are sent for histologic confirmation of complete transection.

Pomeroy Method

This technique involves grasping and elevating a 2-cm midsegment of tube, ligating the tubal loop with a 2-0 plain catgut suture, and then excising the distal portion of the loop (Fig. 43-7.3). Prompt absorption of the suture following surgery causes the ligated ends to fall away, creating a resulting 2- to 3-cm gap that separates the ends.

Wound Closure

The wound is closed as that for other transverse abdominal incisions.

POSTOPERATIVE

The recovery following minilaparotomy is typically rapid and without complication, and women may resume regular diet and activities as tolerated. Sterilization is immediate following surgery, and intercourse may resume at the patient’s discretion. Aside from regret, the risk of long-term physical or psychologic sequelae is low. Peterson and coworkers (2000) found that women who had undergone tubal sterilization were no more likely than those without this surgery to have menstrual abnormalities. Moreover, interval tubal ligation is unlikely to negatively affect sexual interest or pleasure (Costello, 2002).

Salpingostomy describes a lengthwise linear incision of the fallopian tube and is usually used to remove intraluminal ectopic pregnancy contents. In contrast, salpingectomy removes the fallopian tube with sparing of the ovary. Indications are varied, and this procedure may be selected for ectopic pregnancy removal, for sterilization, or for hydrosalpinx removal to improve in vitro fertilization success rates. Also, for ovarian cancer prevention, the Society of Gynecologic Oncology (2013) now recommends consideration of salpingectomy in lieu of tubal ligation or at the time of other pelvic surgery. The fallopian tube may be the origin of pelvic serous carcinomas (Chap. 35).

Laparoscopic surgery offers patients the advantages of shorter hospitalizations, quicker recoveries, and less postoperative pain. Accordingly, laparoscopic treatment of ectopic pregnancy is generally preferred. As a result, laparotomic approaches for salpingectomy and salpingostomy are now reserved typically for patients with ruptured ectopic pregnancies who are hemodynamically unstable or in those with contraindications to laparoscopy. For hemoperitoneum, laparotomy offers fast entry into the abdomen for control of bleeding.

PREOPERATIVE

Consent

Most complications associated with salpingectomy and salpingostomy occur in conjunction with ectopic pregnancies, and the risk of bleeding is prominent. Injury to the ipsilateral ovary, however, is an attendant risk regardless of the indication. In certain cases, if severe, this damage can demand concurrent oophorectomy. Additionally, involvement of the ovary with tubal pathology may necessitate ovarian removal.

If salpingectomy is performed for sterilization, then consenting should mirror that for interval tubal sterilization found in Section 43-7.

Persistent Trophoblastic Tissue

Following any surgical treatment of ectopic pregnancy, trophoblastic tissue can persist. Remnant implants typically involve the fallopian tube, but extratubal trophoblastic implants have been found on the omentum and on pelvic and abdominal peritoneum. Peritoneal implants typically measure 0.3 to 2.0 cm and appear as red-black nodules. As expected, the risk of persistent trophoblast tissue is lower with salpingectomy compared with salpingostomy (Farquhar, 2005).

Preservation of Fertility

Most, but not all, studies show comparable subsequent fertility rates whether salpingectomy or salpingostomy is performed to treat ectopic pregnancy if the other tube is normal. This discussion is detailed in Chapter 7. Thus, with a healthy contralateral tube, neither salpingostomy nor salpingectomy offers a distinct fertility advantage. However, salpingostomy is considered a preferred option for tubal ectopic pregnancy if there is contralateral tubal disease and a desire for fertility. Unfortunately, in some cases of rupture, the extent of tubal damage or bleeding may limit tubal salvage, and salpingectomy may be required.

Patient Preparation

If performed for ectopic pregnancy, both salpingectomy and salpingostomy may be associated with substantial bleeding. Baseline complete blood count (CBC) and β-human chorionic gonadotropin (β-hCG) level are obtained. Patients undergo type and screen to establish blood type. Those with significant bleeding also require a type and crossmatch for packed red blood cells and other blood products as indicated. If performed for interval sterilization, then preparation follows that found in Section 43-7.

Salpingectomy and salpingostomy are associated with low infection rates. Accordingly, preoperative antibiotics are usually not required. Laparotomy dictates venous thrombo­embolism prophylaxis, and options are found in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

In most cases of ectopic pregnancy managed by laparotomy, surgery is an inpatient procedure and requires general anesthesia. For other indications, regional analgesia may be an option. The patient is supine. After anesthesia induction, hair in the planned incision path is clipped if needed; a Foley catheter is placed; and abdominal preparation is completed.

Abdominal Entry

Most salpingectomy or salpingostomy procedures can be managed through a Pfannenstiel incision. However, with a hemodynamically unstable patient and large hemoperitoneum, vertical incision may offer quicker entry.

Salpingectomy

Once access to the pelvic organs has been achieved, the adnexa is elevated. Distal and proximal Babcock clamps are placed around the fallopian tube and direct the tube away from the uterus and ovary. This extends the mesosalpinx (Fig. 43-8.1).

Beginning at the distal, fimbriated end of the tube, one Kelly clamp or hemostat is placed across a 2-cm-long segment of the mesosalpinx, close to the fallopian tube. The clamp’s curve faces the tube. Another clamp is similarly placed, but lies closer to the ovary. These clamps occlude vessels that traverse the mesosalpinx. Scissors then cut the interposed mesosalpinx.

The severed tissue pedicle that is closer to the ovary is tied with 2-0 or 3-0 gauge delayed-absorbable suture, and the clamp is removed. The clamp closer to the tube remains and leaves with the final specimen. Such clamping, cutting, and ligating are repeated serially, with each clamp incorporating approximately 2 cm of mesosalpinx. Progression is directed from the ampullary end of the fallopian tube toward the uterus.

The last clamp is placed across the proximal mesosalpinx and fallopian tube. Scissors then cut the mesosalpinx and tube and free these from the uterus. This pedicle is similarly ligated.

Salpingostomy

Surgical steps for salpingostomy mirror those used in laparoscopic salpingostomy and can be reviewed in Section 44-5. To summarize, the affected fallopian tube is elevated with Babcock clamps. At the ectopic pregnancy site, the tube is sharply incised lengthwise on its antimesenteric border. The incision, usually 1 to 2 cm long, varies based on pregnancy size. The products of conception are grasped and gently extracted or are delivered by hydrodissection. Bleeding sites are made hemostatic with electrosurgical coagulation, and the tubal incision is left to heal by secondary intention.

Wound Closure

The pelvis is irrigated and rid of blood and tissue debris. The abdominal incision is closed as previously described for vertical or Pfannenstiel incision.

POSTOPERATIVE

In cases performed for ectopic pregnancy, salpingectomy or salpingostomy represents pregnancy termination. Accordingly, the Rh status of the patient should be evaluated. Administration of 50 or 300 μg (1500 IU) of anti-D immune globulin intramuscularly within 72 hours after pregnancy termination in Rh negative women can dramatically lower the risk of alloimmunization in future pregnancies.

Because of the increased risk of persistent trophoblastic tissue in patients undergoing salpingostomy, serial weekly serum β-hCG levels should be measured until undetectable levels are reached. During this time, contraception should be used to avoid confusion between persistent trophoblastic tissue and a new pregnancy.

For elective sterilization, postoperative instructions follow those for interval tubal sterilization in Section 43-7. For all indications, resumption of activity and diet follow that for laparotomy.

Interstitial pregnancy develops in a distensible portion of the tube surrounded by myometrium (Fig. 43-9.1). This location often permits pregnancies to attain greater size than ectopic pregnancy at other sites. Also, uterine rupture at the cornu, where uterine and ovarian arteries anastomose, can lead to brisk and significant hemorrhage. Fortunately, high-resolution sonography, β-hCG testing, and use of established diagnostic criteria have led to earlier diagnosis of interstitial pregnancy. This averts rupture in many circumstances.

In selected cases, this unusual type of ectopic pregnancy may be managed medically, but it is more frequently managed by various surgical techniques. Cornuostomy is analogous to linear salpingostomy for tubal ectopic pregnancy, whereas cornual wedge resection removes the interstitial pregnancy with its surrounding myometrium and fallopian tube (Moawad, 2010). Cornual wedge resection, often performed via laparotomy, has remained a cornerstone of therapy. However, many cases of interstitial pregnancy are now managed laparoscopically (Hwang, 2011). Factors to consider in selecting surgical route and specific procedure include gestational age, presence of rupture, hemodynamic stability, patient’s desire for future fertility, and surgeon’s preference and skill.

This discussion describes a laparotomic approach. However, the principles and surgical steps presented here are applicable to laparoscopic management with only minor modifications.

PREOPERATIVE

Patient Evaluation

In some cases, particularly those in which the cornu has ruptured and the woman is hemodynamically unstable, fluid resuscitation and blood transfusion are initiated preoperatively. Further, because there is risk for excessive intraoperative bleeding, a patient is typed and crossmatched for packed red blood cells and other blood products as indicated. A patient is counseled regarding the possible need for blood products, which includes anti-D immune globulin for those with Rh-negative blood. Baseline CBC and β-hCG levels are obtained.

Additional risks include removal of the ipsilateral ovary and the possibility of hysterectomy for uncontrollable bleeding. In the event that the patient has completed her childbearing, tubal ligation or bilateral salpingectomy or rarely even hysterectomy may be acceptable at the time of surgery.

Patient Preparation

Other than optimizing hemodynamic stability of the patient and ensuring blood availability, no special preparation is required. Prophylactic antibiotics or bowel preparation are generally not required. Laparotomy dictates venous thromboembolism prophylaxis, and options are found in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Cornual wedge resection and cornuostomy are usually performed under general anesthesia, particularly if cornual rupture is suspected. The patient is supine. After anesthesia induction, hair in the planned incision path is clipped if needed; a Foley catheter is inserted; and abdominal preparation is completed.

Abdominal Entry

Either a transverse or vertical incision may be used depending on the clinical situation as discussed in Section 43-1.

Exposure

In the absence of cornual rupture and active bleeding, the bowel is packed away to provide adequate exposure of the pelvis. A self-retaining retractor may then be placed. If significant hemoperitoneum is encountered upon abdominal entry, the operator can attempt to remove obscuring blood with suction and laparotomy sponges. Failing this, the surgeon may consider manually elevating the uterus out of the pelvis where it may be inspected for rupture and hemorrhage. The uterus can be compressed between the operator’s thumb and fingers to tamponade bleeding. Two heavy clamps can then be place across the base of the cornu. In rare cases, temporary compression of the aorta may be helpful if bleeding is torrential and poorly controlled.

Inspection of the Pelvis

The location of the ectopic pregnancy is identified. Additional information including presence or absence of rupture, pregnancy size, amount of bleeding, and appearance of the contralateral (unaffected) adnexa is needed before deciding on the exact procedure to perform.

Vasopressin Injection

For either cornuostomy or cornual wedge resection, dilute vasopressin (20 units in 30-100 mL of normal saline) may be injected into the myometrium surrounding the interstitial pregnancy to aid hemostasis. Needle aspiration prior to injection is imperative to avoid intravascular injection of this potent vasoconstrictor. The anesthesiologist is concurrently informed of vasopressin injection because a sudden increase in patient blood pressure may follow injection. Blanching at the injection site is expected.

Cornuostomy: Incision

A linear incision is made through the uterine serosa and myometrium overlying the interstitial pregnancy (Fig. 43-9.2). As the incision is carried downward, some products of conception may extrude through the incision (Fig. 43-9.3). Products of conception may be removed by means of blunt, sharp, suction, or hydrodissection (Fig. 43-9.4). Despite vasopressin, bleeding from the myometrium is common and is best managed with electrosurgical coagulation or figure-of-eight stitches with 2-0 gauge absorbable or delayed-absorbable suture.

Cornuostomy: Incision Closure

The myometrial incision is usually closed with absorbable or delayed-absorbable suture in an interrupted or continuous running fashion (Fig. 43-9.5) A gauge of sufficient strength to prevent breakage during muscle approximation is selected, typically 2-0 or 0-gauge. For this, chromic suture may be preferred due to its slight elasticity that provides tensile strength and minimal tissue cutting. Closure may be completed with one layer of sutures or may require two to three layers to aid hemostasis, avert hematoma formation, and reapproximate myometrium. Additionally, some prefer a subserosal closure, similar to a subcuticular running stitch, as a final layer. This theoretically minimizes the amount of exposed suture and thereby limits adhesion formation.

Cornual Wedge Resection: Salpin­gectomy

With this approach, the pregnancy, surrounding myometrium, and ipsilateral fallopian tube are excised en bloc. The fallopian tube is removed to avoid future ectopic pregnancy in this tube. Such pregnancies form when the ipsilateral ovary’s eggs are fertilized by sperm that travel out the contralateral tube and are transported by peritoneal fluid to the isolated and ligated tube.

Initially, salpingectomy is completed as described in Section 43-8.1. To summarize, the mesosalpinx is serially clamped and ligated across its length (Fig. 43-9.6). This separates the tube from its mesosalpinx and ipsilateral ovary (Fig. 43-9.7).

Cornual Wedge Resection: Myo­metrial Incision

Following vasopressin injection, the cornual serosa surrounding the pregnancy is incised with an electrosurgical blade (Fig. 43-9.8). The incision is angled inward as it is deepened. This creates a wedge into the myometrium (Fig. 43-9.9). Hemostasis can be achieved with electrosurgical blade coagulation or with sutures.

Cornual Wedge Resection: Incision Closure

The myometrial incision is usually closed in two to three layers with absorbable or delayed-absorbable suture in an interrupted or continuous running fashion. As with cornuostomy, some recommend a final subserosal layer closure. However, depending on the degree of wound tension created by the contracted myometrium, this suture may pull through the serosa, and a simple interrupted or running suture line may be required to approximate the serosa (Fig. 43-9.10).

As noted earlier, there can be cases with rupture and brisk bleeding, in which two clamps are quickly placed across the base of the cornu to halt hemorrhage. In these cases, salpingectomy is similarly completed. Then, the cornual myometrium above these clamps is sharply removed. The myometrium within each clamp is then suture ligated with a transfixing stitch.

POSTOPERATIVE

After surgery, patient care in general follows that described for laparotomy. As with salpingostomy for treatment of tubal pregnancy, there is increased risk of persistent trophoblastic tissue following cornuostomy. Therefore, serial β-hCG levels are followed postoperatively until a negative test result is obtained. For Rh-negative women, 50 or 300 μg (1500 IU) of anti-D immune globulin is given intramuscularly within 72 hours after pregnancy termination to lower the risk of alloimmunization in future pregnancies. Patients should also be counseled that there is also an increased risk of future ectopic pregnancy in the remaining tube following an interstitial pregnancy. Last, as is the case with other types of uterine surgery such as classical cesarean delivery or myomectomy, the uterine rupture rate in subsequent pregnancies and particularly during labor is increased. For this reason, delivery by cesarean at term before labor onset is generally recommended.

Myomectomy involves surgical removal of leiomyomas from their surrounding myometrium. Indications can include abnormal uterine bleeding, pelvic pain, infertility, and recurrent miscarriage. Hysterectomy is chosen to treat many of these indications. However, myomectomy is often selected by those desiring organ preservation for childbearing or those wishing to avoid hysterectomy.

Myomectomy often requires laparotomy. However, laparoscopic excision may be performed by those with skills in laparoscopic suturing and is described in Section 44-8 (Seracchioli, 2000; Sizzi, 2007).

PREOPERATIVE

Patient Evaluation

Because of their influence on pre- and intraoperative planning, leiomyoma size, number, and location are evaluated prior to surgery with sonography, MR imaging, or hysteroscopy (Chap. 9). For example, submucous tumors are more easily removed hysteroscopically (Section 44-14), whereas intramural and serosal types typically require laparotomy or laparoscopy. Leiomyomas may be small and buried within the myometrium. Thus, accurate information as to leiomyoma number and location aids complete excision. Last, multiple large tumors or those that are located in the broad ligament, encroach on the tubal ostia, or involve the cervix may increase the risk of conversion to hysterectomy. Patients are so counseled.

Consent

Myomectomy has several risks including significant bleeding and need for transfusion. Moreover, uncontrolled hemorrhage or extensive myometrial injury during tumor removal may force hysterectomy. Fortunately, rates of conversion to hysterectomy during myomectomy are low and range from 0 to 2 percent (Iverson, 1996; LaMorte, 1993; Sawin, 2000). Postoperatively, the risk of pelvic adhesion formation is significant. Also, leiomyomas can recur.

Patient Preparation

Hematologic Status

Abnormal uterine bleeding is a common indication for myomectomy. As a result, many women who elect to undergo this surgery are anemic. In addition, significant intraoperative blood loss during myomectomy is possible. Accordingly, attempts to resolve anemia and bleeding prior to surgery are pursued. Toward this goal, oral iron therapy, gonadotropin-releasing hormone (GnRH) agonists, and progesterone antagonists may have benefits (Chap. 9).

In addition to preoperative control of abnormal uterine bleeding, these agents have been shown to significantly decrease uterine volume after several months of use (Benagiano, 1996; Friedman, 1991). Decreased uterine size following treatment may allow a less invasive surgical procedure. For example, myomectomy may be completed through a smaller laparotomy incision or by laparoscopy or hysteroscopy (Lethaby, 2002; Mencaglia, 1993). These agents have also been found to diminish leiomyoma vascularity and uterine blood flow (Matta, 1988; Reinsch, 1994). For this surgery, there is conflicting evidence regarding a final benefit of adhesion prevention (Coddington, 2009; Imai, 2003).

The use of preoperative GnRH agonists, however, may also have disadvantages. Within leiomyomas, GnRH agonists can incite hyaline or hydropic degeneration, which may obliterate the pseudocapsule connective tissue interface between the tumor and the myometrium. Such obliterated cleavage planes may lead to tedious and lengthy tumor enucleation (Deligdisch, 1997). Moreover, studies have shown higher rates of leiomyoma recurrence in women treated with GnRH agonists prior to myomectomy (Fedele, 1990; Vercellini, 2003). Leiomyomas treated with these agents may shrink in volume and be missed during surgical removal.

For these reasons, GnRH agonists are not used routinely in all patients undergoing myomectomy. They can be recommended for preoperative use in women with greatly enlarged uteri or preoperative anemia or in cases in which a decrease in uterine volume would allow a less invasive approach to leiomyoma removal.

Similar to GnRH agonists, the oral progesterone agonists preoperatively shrink myoma volume and diminish menorrhagia (Donnez, 2012a,b). Currently available outside the United States, ulipristal acetate (Esmya) in dosages of 5 mg or 10 mg daily may be used during the 3 months prior to surgery.

The risk of blood transfusion varies among studies and ranges from less than 5 percent to nearly 40 percent (Darwish, 2005; LaMorte, 1993; Sawin, 2000; Smith, 1990). Accordingly, in women with large uteri, especially those with multiple leiomyomas, cell-saver blood scavenger and reuse techniques may be selected (Son, 2014; Yamada, 1997). Indications, benefits, and limitations are discussed fully in Chapter 40.

Also with large leiomyomas, tourniquets or vasopressin may fail to adequately limit bleeding. For these, preoperative uterine artery embolization (UAE) on the morning of surgery may be an effective tool to limit blood loss. And unlike GnRH agonist use, UAE allows tissue planes to be preserved (Chua, 2005; Ngeh, 2004; Ravina, 1995).

Several disadvantages of UAE include risks for subsequent pregnancy complications, collateral ovarian infarction, and formation of uterine synechiae, among others discussed in Chapter 9. Thus, preoperative UAE may best be limited to patients with large uteri in whom excessive blood loss is expected and in those not seeking future pregnancy.

Prophylaxis

Few studies address the benefits of preoperative antibiotic use. Iverson and coworkers (1996), in their analysis of 101 myomectomy cases, found that although 54 percent of cases received prophylaxis, infectious morbidity was not lowered compared with cases in which antibiotics were not used. However, in cases performed for infertility, because of the potential for tubal adhesions associated with pelvic infection, antibiotic prophylaxis has been advocated (Milton, 2013). For those in whom prophylaxis is planned, selection can follow that for hysterectomy (Table 39-6). For all cases, because the risk of conversion to hysterectomy is present, vaginal preparation immediately prior to surgical draping is warranted.

With myomectomy, the risk of bowel injury is low. Thus, bowel preparation is typically not required unless extensive adhesions are anticipated. Last, laparotomy dictates venous thromboembolism prophylaxis, and options are found in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Myomectomy performed through a laparotomy incision is typically an inpatient procedure performed under general or regional anesthesia. The patient is supine. After anesthesia induction, hair in the planned incision path is clipped if needed; a Foley catheter is inserted; and abdominal preparation is completed.

The choice of Pfannenstiel incision is typically appropriate for uteri 14-weeks size or smaller (Section 43-2). Larger uteri usually require a midline vertical abdominal incision.

Following abdominal entry, the surgeon inspects the serosal surface to identify leiomyomas to be removed. Additionally, squeezing palpation of the myometrium before and during the surgery will help identify firm buried intramural or submucous leiomyomas.

Tourniquets have been used for years to temporarily occlude blood flow through the uterine arteries. Because the uterus receives collateral flow through the ovarian arteries, some tourniquet techniques include occlusion of both uterine and ovarian vessels. First, bilateral windows are created in the leaves of the broad ligament at the level of the internal cervical os. A Penrose drain or Foley catheter is threaded through the opening to encircle the uterine isthmus. Once in place, the Penrose drain is tied or the ends of the Foley catheter are clamped to compress the uterine vessels. Alternatively, the uterine arteries can be ligated bilaterally (Helal, 2010; Sapmaz, 2003). In combination with uterine artery compression, occlusion of the uteroovarian ligaments or infundibulopelvic ligaments to compress the ovarian arteries has been described (Al-Shabibi, 2009; Taylor, 2005). Large, isthmic, or broad-ligament leiomyomas, however, may limit the use of tourniquets in some.

8-Arginine vasopressin (Pitressin) is a sterile, aqueous solution of synthetic vasopressin. It is effective in limiting uterine blood loss during myomectomy because of its ability to cause vascular spasm and uterine muscle contraction. Compared with placebo, vasopressin injection significantly decreases blood loss during myomectomy (Frederick, 1994). Compared with tourniquet techniques, vasopressin injection has also been associated with either comparable or less intraoperative blood loss, with equally low patient morbidity, and lower myometrial hematoma formation rates (Darwish, 2005; Fletcher, 1996; Ginsburg, 1993).

Each vial of Pitressin is standardized to contain 20 pressor units/mL, and doses used for myomectomy are 20 U diluted in 30 to 100 mL of saline (Frishman, 2009). Vasopressin is typically injected along the planned serosal incision(s). The plasma half-life of this agent is 10 to 20 minutes. For this reason, injection of vasopressin is ideally discontinued 20 minutes prior to uterine repair to allow evaluation of bleeding from myometrial incisions (Hutchins, 1996).

The main risks associated with local vasopressin injection result from inadvertent intravascular infiltration and include transient increases in blood pressure, bradycardia, atrioventricular block, and pulmonary edema (Deschamps, 2005; Tulandi, 1996). For these reasons, patients with a history of cardiovascular disease, cardiomyopathy, congestive heart failure, uncontrolled hypertension, migraine, asthma, and severe chronic obstructive pulmonary disease may not be candidates for vasopressin use. In addition to vasopressin, other less-researched agents for blood loss prevention have been reviewed by Kongnyuy and Wiysonge (2014).

Because of postoperative adhesion formation risks, surgeons ideally minimize the number of serosal incisions and attempt to place incisions on the anterior uterine wall. Tulandi and colleagues (1993) found that posterior wall incisions result in a 94-percent adhesion formation rate compared with a 55-percent rate for anterior incisions.

For most patients, a midline vertical uterine incision allows removal of the greatest number of leiomyomas through the fewest incisions. The length should accommodate the approximate diameter of the largest tumor. The incision depth should afford access to all leiomyomas (Fig. 43-10.1). To reach lateral tumors, a surgeon may create lateral myometrial incisions within the initial central incision. However, at times, separate incision may be required to excise tumors. In these instances, a horizontal incision decreases the number of arcuate vessels transected.

The first leiomyoma is grasped with a Lahey or single-tooth tenaculum (Fig. 43-10.2). Applying traction on the leiomyoma outward and away from the myometrial incision aids in the development of a tissue plane between myometrium and leiomyoma. Sharp and blunt dissection of the pseudocapsule surrounding the leiomyoma frees the tumor from the adjacent myometrium.

Hemorrhage during myomectomy primarily develops during tumor enucleation and is positively correlated with preoperative uterine size, total weight of leiomyomas removed, and operating time (Ginsburg, 1993). Approximately two to four main arteries feed each leiomyoma and enter the tumor at unpredictable sites. Accordingly, surgeons should watch for these vessels, ligate them prior to transection when possible, and be ready to immediately grasp them with hemostats for ligation or fulguration if lacerated during tumor excision (Fig. 43-10.3).

Smaller, internal incisions into the myometrium may be required to excise all leiomyomas. If the endometrial cavity is entered, it should be closed with a running suture of 4-0 or 5-0 gauge delayed-absorbable suture (Fig. 43-10.4).

After removal of all tumors, redundant serosa may be excised. Smaller internal myometrial incisions are closed first with delayed-absorbable suture (see Fig. 43-10.4). The myometrium is then closed in several layers to improve hemostasis and prevent hematoma formation. A gauge of sufficient strength to prevent breakage during muscle approximation is selected, typically 2-0 to 0-gauge.

Closure of the serosal incision using a running baseball stitch or a subserosal running closure, similar to a running subcuticular closure, may help to limit adhesion formation. For this, 4-0 or 5-0 monofilament, delayed-absorbable suture may be selected. Moreover, absorbable adhesion barriers may help reduce the incidence of adhesion formation following myomectomy (Ahmad, 2015; Canis, 2014; Tinelli, 2011).

POSTOPERATIVE

After surgery, care in general follows that described for laparotomy. Febrile morbidity of greater than 38.0°C is a common event following myomectomy (Iverson, 1996; Rybak, 2008). Purported causes include atelectasis, myometrial incisional hematomas, and factors released with myometrial destruction. Although fever is common following myomectomy, pelvic infection is not. For example, LaMorte and colleagues (1993) noted only a 2-percent rate of pelvic infection in their analysis of 128 myomectomy cases.

Following myomectomy, there are no clear guidelines as to the timing of pregnancy attempts. Darwish and associates (2005) performed sonographic examinations on 169 patients after myomectomy. Following myometrial indicators, they concluded that wound healing is usually completed within 3 months. There are no clinical trials that address the issue of uterine rupture and therefore route of delivery of pregnancies occurring after myomectomy (American College of Obstetricians and Gynecologists, 2012). Management of these cases requires sound clinical judgment and individualization of care.

Prolapse of a pedunculated submucosal leiomyoma is an unusual occurrence but certainly not rare. Vaginal myomectomy is usually a relatively simple procedure and is frequently curative for the patient. Myoma and stalk size and patient discomfort are the most important variables for management. With a thin stalk, simply twisting the leiomyoma slowly off its stalk may be sufficient for removal. With larger stalk diameter or greater patient pain, removal in the operating room is typically preferred. Finally, for those with a large obstructive myoma on a thick, short stalk, hysterectomy may be necessary (Caglar, 2005; Golan, 2005).

PREOPERATIVE

Patient Evaluation

In many cases, diagnosis of a prolapsed pedunculated submucosal leiomyoma will be obvious, as will the size of the prolapsed leiomyoma. However, as many of these patients present with abnormal uterine bleeding, evaluation for other less obvious causes of abnormal bleeding is appropriate. In other cases, only partial prolapse of a leiomyoma through the cervix may preclude assessment of total leiomyoma and stalk size, or the mass may be of unclear etiology. Accordingly, imaging studies, particularly transvaginal or transabdominal sonography or both, may yield additional information beyond pelvic examination. Specifically, uterine size, shape, and degree of involvement with additional leiomyomas or other pathology can be obtained. Moreover, biopsy of any mass of uncertain etiology is considered, and Tischler biopsy forceps may be selected (Fig. 29-16). If required, Monsel solution can be applied to control bleeding from the biopsy site similar to that following colposcopic biopsy.

Consent

Risks with vaginal myomectomy are low. Uncontrollable bleeding and procedural failure are potential complications. Rarely, severing a stalk on great tension may concomitantly resect the attached uterine wall and injure intraabdominal organs. The possibility of hysterectomy and its consequences are also discussed with the patient beforehand. Leiomyoma prolapse recurrence is uncommon but may occur if additional submucosal leiomyomas are present or develop within the uterus.

Patient Preparation

In an otherwise healthy woman, little preparation is needed for vaginal myomectomy. However, uterine bleeding with leiomyoma prolapse is common, and hypovolemia and acute blood loss anemia are corrected as needed with crystalloid and blood products (Chap. 40). If fever is present and infection of the prolapsed leiomyoma or lower genital tract is suspected, treatment with broad-spectrum antibiotics are initiated prior to vaginal myomectomy. Suitable options are found in Table 39-6. The need for thromboembolism prophylaxis will vary by patient age and anticipated length of surgery as outlined in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

The patient is placed in standard dorsal lithotomy position. Vaginal myomectomy may be performed under general or regional anesthesia, intracervical or paracervical blockade, conscious sedation, or intramuscular analgesia. For those women who are taken to the operating room at our institution, we usually prefer general anesthesia for several reasons. First, hysteroscopy is often done following vaginal myomectomy to further evaluate the uterine cavity and status of the stalk. Secondly, many leiomyomas are bulky and require at least a moderate amount of manipulation and vaginal retraction for removal.

An examination is done once the patient is relaxed to assess the size of the prolapsed leiomyoma; location, length, and thickness of the stalk; and general pelvic anatomy. The vagina is then surgically prepared, and the bladder is drained.

Leiomyoma Stalk Ligation

To retract the posterior vaginal wall, an Auvard weighted vaginal speculum is positioned. Heaney retractors are used as needed for sidewall and anterior vaginal wall retraction. The prolapsed leiomyoma is grasped with a tenaculum. Traction is applied on the leiomyoma to allow access to the stalk (Fig. 43-11.1). Excessive traction on the leiomyoma is avoided. This can invert the uterine wall that is attached to the stalk and thereby risk resection of this wall rather than the proximal stalk. In addition, undue traction may avulse the tumor prior to stalk ligation.

The stalk is doubly ligated with delayed-absorbable suture. Preformed knotted loops with a knot pusher (as used in laparoscopy cases) work well in this setting (Fig. 41-35). With this, the tenaculum is removed to place a loop and then reclamped. In contrast, manual knot tying may be technically difficult given the size of the obstructing leiomyoma, the stalk length (or lack thereof), and the cramped vaginal operating space. In such cases, tips of a Heaney right-angle clamp can be maneuvered past the myoma and then across the stalk.

Leiomyoma Removal

The stalk is then sharply incised at an appropriate point distal to the ligature to prevent the ligature from slipping off (Fig. 43-11.2). With complete stalk transection, the prolapsed leiomyoma is freed for removal, and the ligated stalk retracts into the uterine cavity (Fig. 43-11.3). If a Heaney clamp has been placed, then the stalk is severed, the mass is removed, and a ligature is placed around the proximal stalk. As the suture is tied, the clamp is removed.

As alternatives, the stalk may be incised electrosurgically without ligature placement, or the leiomyoma can be twisted from its stalk if the stalk is not excessively thick. After leiomyoma removal, hysteroscopy may optionally be performed to assess hemostasis and the uterine cavity.

POSTOPERATIVE

No special care beyond routine postoperative surveillance is necessary following vaginal myomectomy for a pedunculated prolapsed leiomyoma. Regular diet and activities are resumed quickly and can be individualized.

Hysterectomy is one of the most frequently performed gynecologic procedures, and more than 500,000 women undergo this procedure for benign disease annually in the United States (Jacoby, 2009). Of benign reasons, symptomatic leiomyomas and pelvic organ prolapse are the most frequent, although adenomyosis, endometriosis, chronic pain, and premalignant uterine or cervical disease are also relatively common.

PREOPERATIVE

Patient Evaluation

To reach the preoperative diagnosis, testing varies on clinical signs and symptoms and is discussed within the respective chapters covering specific etiologies. Prior to hysterectomy, all patients require cervical cancer screening. With abnormal findings, further evaluation is completed to exclude invasive cancer, which is treated instead with radical hysterectomy or chemoradiation. Similarly, women at risk for endometrial cancer and whose indication includes abnormal bleeding are also usually screened before surgery (Chap. 8). Last, concurrent cervical infection or bacterial vaginosis is sought for preoperative eradication to lower postoperative infection risks.

Decision-making for Approach Selection

Hysterectomy may be completed using an abdominal, vaginal, laparoscopic, or robotic approach, and selection is influenced by many factors. For example, shape and size of the uterus and pelvis, surgical indications, presence or absence of adnexal pathology, extensive pelvic adhesive disease, surgical risks, hospitalization and recovery length, hospital resources, and surgeon expertise are all weighed once hysterectomy is planned. Each approach carries distinct advantages and disadvantages, discussed subsequently.

Vaginal Hysterectomy

Surgeons usually choose this approach if the uterus is relatively small, extensive adhesions are not anticipated, no significant adnexal pathology is expected, and some degree of pelvic organ descent is present. When this procedure is compared with abdominal hysterectomy, patients usually benefit from faster recovery and from reduced hospital stays, costs, and postoperative pain (Johnson, 2005; Nieboer, 2009).

Abdominal Hysterectomy

Despite the advantages of vaginal hysterectomy, most uteri in the United States are removed through an abdominal incision (Jacoby, 2009). Either a transverse or vertical incision may be selected depending on the clinical setting.

Abdominal hysterectomy allows the greatest ability to manipulate pelvic organs. Thus, it may be preferred if large pelvic masses or extensive adhesions are anticipated. Additionally, an abdominal approach affords access to the ovaries if oophorectomy is desired, to the space of Retzius or presacral space if concurrent urogynecologic procedures are planned, or to the upper abdomen for cancer staging. However, for surgeons with advanced skills in minimally invasive surgery (MIS), most of these limitations are overcome, and their indications for abdominal hysterectomy may be few. That said, abdominal hysterectomy typically requires less operating time than laparoscopic or robotic hysterectomy and requires no advanced MIS expertise or instrumentation. Moreover, the Food and Drug Administration (FDA) (2014) has recently discouraged the use of laparoscopic power morcellators due to the potential dispersion of occult cancer cells. While data are being collected regarding this risk, many surgeons and patients may forego MIS hysterectomy for larger uteri, and thus rates of abdominal hysterectomy may increase.

Disadvantages of abdominal hysterectomy include longer patient recovery and hospital stays, increased incisional pain, and greater risk of postoperative fever and wound infection (Marana, 1999; Nieboer, 2009). Additionally, compared with a vaginal approach, abdominal hysterectomy is associated with greater risk for ureteral injury, but lower rates of bladder injury (Frankman, 2010; Gilmour, 2006).

Laparoscopic Hysterectomy

Selected more and more frequently, this hysterectomy group uses laparoscopic techniques to complete some or all steps of hysterectomy, and specific definitions are provided in Chapter 44 (Turner, 2013). Although criteria vary depending on surgeon skill, this approach is often selected if the uterus is not excessively large, extensive adhesions are not expected, and some limitation deters vaginal hysterectomy alone. Patient recovery, hospital stays, and postoperative pain scores are comparable with those of vaginal hysterectomy, but a laparoscopic approach allows greater visualization and access to the abdomen and pelvis. This may be advantageous if oophorectomy is planned or if adhesive disease or bleeding is encountered. However, laparoscopy typically requires longer operating times, expensive equipment, and MIS expertise. In addition, in most studies, laparoscopic hysterectomy has been associated with greater rates of ureteral injury than either abdominal or vaginal hysterectomy (Frankman, 2010; Gilmour, 2006; Mamik, 2014).

Approach Selection

If all factors are equal, vaginal hysterectomy should be considered. However, with large pelvic masses or large uteri, with risk of gynecologic cancer, with extensive adhesions, or with poor uterine descent, either abdominal or laparoscopic hysterectomy may be required. Of note, surgical expertise is factored into the decision and strongly dictates the approach selected.

Total versus Supracervical Hysterectomy

Prior to hysterectomy, the decision to concurrently remove the cervix is discussed with the patient. Hysterectomy may include removal of the uterus and cervix, termed total hysterectomy, or may involve only the uterine corpus, called supracervical hysterectomy (SCH) (Fig. 43-12.1). The term subtotal hysterectomy is ambiguous and is not a preferred term.

Most hysterectomies performed are total, but SCH may be selected preoperatively. For example, SCH is purported to reduce the risk of mesh erosion at the cuff if concurrent hysterectomy and sacrocolpopexy are planned (Osmundsen, 2012; Tan-Kim, 2011). At one point, SCH was also suggested to improve urinary, bowel, or sexual function compared with total abdominal hysterectomy. But, several studies have shown no short- or long-term differences in these functions between total abdominal or supracervical hysterectomy (Learman, 2003; Lethaby, 2012; Thakar, 2002). Frequently, SCH may be an intraoperative decision during cases in which excision of the cervix risks increased bleeding, surrounding organ damage, or increased operating time.

As a disadvantage, 10 to 20 percent of women following SCH will still note cyclic vaginal bleeding, presumably from retained isthmic endometrium in the cervical stump. Procedures that ablate or core out the endocervical canal can help prevent this complication (Schmidt, 2011). Also, pelvic organ prolapse may develop (Hilger, 2005). For either complication, cervical stump excision, termed trachelectomy, may be required. Last, critics noted the persistent risk for cancer in the conserved stump. However, the risk for cervical cancer in these women is comparable to that in women without hysterectomy. Moreover, the prognosis for cervical stump cancer mirrors that in women with a complete uterus (Hannoun-Levi, 1997; Hellstrom, 2001).

In sum, SCH alone offers no distinct long-term advantages compared with total abdominal hysterectomy (American College of Obstetricians and Gynecologists, 2013b). The risk of persistent bleeding following surgery may deter many women and clinicians from its use. Moreover, although data are limited, trachelectomy following SCH may be surgically challenging due to scarring of bowel or bladder to the stump. Despite these disadvantages, if concurrent sacrocolpopexy is planned, SCH may lower mesh erosion rates. However, current data for this are limited and retrospective, and future research is needed.

Consent

For most women with indications, hysterectomy is a safe and effective treatment that typically leads to an improved postoperative quality of life and psychological outcome (Hartmann, 2004; Kuppermann, 2013). However, pelvic organs may be injured during surgery, and vascular, bladder, ureteral, and bowel injury are most commonly cited. Accordingly, these and the risks of wound infection, blood loss, and transfusion are discussed with the patient before surgery. Infrequently, unintended adnexectomy may be required, and if bilateral, will create iatrogenic menopause. Importantly, patients should understand the sterilizing effects of hysterectomy.

Concurrent Adnexal Surgery

Hysterectomy is frequently performed with other operations. Pelvic reconstructive surgeries and bilateral salpingo-oophorectomy (BSO) or salpingectomy are among the most frequent.

Bilateral fallopian tubes and ovaries are prophylactically removed in approximately 40 percent of hysterectomy cases performed for benign indications in the United States (Asante, 2010). In a woman younger than 40 years, ovaries are typically conserved because continued estrogen production is expected until her late 40s. In those older than 50 years, BSO is common. However, for women in their 40s, the decision to prophylactically remove ovaries is controversial.

Proponents of prophylactic BSO between 40 and 50 argue that the procedure lowers future ovarian cancer risk and is estimated to prevent 1000 new cases of ovarian cancer each year (American College of Obstetricians and Gynecologists, 2014b). In addition, patients with retained ovaries may require future surgery for subsequent benign ovarian disease. This risk approximates 3 percent at 10 years posthysterectomy (Casiano, 2013). Specifically, women with endometriosis, pelvic inflammatory disease, and chronic pelvic pain are at greater risk for reoperation. And, if later oophorectomy is required, the risk of ureteral or bowel injury due to adhesions encasing the retained ovary is increased from that with primary BSO. Last, the duration of significant ovarian estrogen production for many will be shortened following hysterectomy. For example, Siddle and coworkers (1987) noted that the mean age of ovarian failure in a group undergoing hysterectomy was 45 years. This was significantly lower than the mean age of 49 years in a control group not receiving surgery.

However, arguments for ovarian conservation are convincing as well. If ovaries are retained during hysterectomy, ovarian cancer risk is still decreased 40 to 50 percent by the hysterectomy itself (Chiaffarino, 2005; Rice, 2013). Additionally, conservation delays the long-term effects of hypoestrogenism (Chap. 21). Parker and colleagues (2013) noted higher ovarian and slightly elevated breast cancer rates but a lower all-cause mortality rate in women after hysterectomy with ovarian conservation compared with those electing BSO without estrogen replacement therapy (ERT). Although these rates became nearly equal in those electing BSO and then receiving postoperative ERT, concerns regarding ERT compliance have been noted. Castelo-Branco and coworkers (1999) found that after 5 years following hysterectomy and BSO, only one third of patients still continued their ERT. Most stopped due to cancer concerns. In addition to loss of estrogen, ovarian androgen production is removed, and its importance in later life has not been entirely delineated (Olive, 2005). The American College of Obstetricians and Gynecologists (2014b) recommends strong consideration of ovarian retention in premenopausal women who are not at increased genetic risk for ovarian cancer. Trends in the United States show a significant decline in BSO rates for those younger than 55 (Novetsky, 2011; Perera, 2013).

Even if ovaries are conserved, the Society of Gynecologic Oncology (2013) encourages consideration of concurrent bilateral salpingectomy during hysterectomy. This practice is hoped to lower peritoneal serous carcinomas (Chap. 35). That said, the degree of compromise of ovarian blood supply and long-term function by this resection is not fully known, and discussion of this point should be part of preoperative consenting.

Patient Preparation

Because of the risk of postoperative wound and urinary tract infection following hysterectomy, patients typically receive antibiotic prophylaxis with either a first- or second-generation cephalosporin (American College of Obstetricians and Gynecologists, 2014a). These and suitable alternatives are found in Table 39-6. As noted in Chapter 39, preoperative mechanical bowel preparation may be implemented depending on anticipated surgical circumstances. Fortunately, the risk of bowel injury with hysterectomy in general is low, and thus many forego evacuation measures for their patients. Laparotomy dictates venous thromboembolism prophylaxis, and options are found in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Abdominal hysterectomy is typically performed under general or regional anesthesia. The patient is often supine. But if concomitant vaginal procedures are planned, the patient is placed in low lithotomy position in adjustable booted stirrups. After anesthesia induction, hair in the planned incision path is clipped if needed; a Foley catheter is inserted; and abdominal preparation is completed.

Abdominal Entry

Either a transverse or a vertical incision may be used for hysterectomy, and clinical factors influence selection.

Exposure

Following entry into the abdomen, a self-retaining retractor such as an O’Connor-O’Sullivan or a Balfour retractor is placed. The pelvis and abdomen are visually and manually explored, and the bowel is packed from the operating field. The uterus is grasped and elevated from the pelvis. If extensive adhesions are present, normal anatomic relationships are restored. Hysterectomy may be performed by one surgeon, but commonly two surgeons are present, with each typically operating on his or her side of the uterus.

Round Ligament Transection

Curved Kelly (pean) clamps are placed immediately lateral to each uterine cornu to permit uterine manipulation. Hysterectomy begins with division of one round ligament at its midpoint (Fig. 43-12.2). This provides entry into the retroperitoneal space for ureter identification and access to the uterine artery and cardinal ligament for later transection. The round ligament is grasped with tissue forceps and elevated. A transfixing stitch using 0-gauge delayed-absorbable suture is placed approximately 1 cm lateral to the planned division site. The first bite of this stitch passes through an avascular site of the mesoteres beneath the round ligament, whereas the transfixing bite pierces the round ligament medial to first bite. This prevents hematoma formation between the transfixing stitch and pelvic sidewall. A second simple stitch of similar suture is placed 1 to 2 cm medial to the first and through an avascular site in the mesoteres and beneath the round ligament. These sutures prevent bleeding from Sampson artery and aid tissue manipulation. Once secured, sutures are held by hemostats and directed outward to create tension along the interposed ligament. The round ligament is then divided, and the incision line is directed deeply into the first 1 to 2 cm of the broad ligament.

Anterior Broad Ligament Leaf

With this action, the broad ligament separates to create anterior and posterior leaves. Between them, loose areolar connective tissue is seen. To incise the anterior leaf, the round ligament sutures are placed on tension. Metzenbaum scissors are introduced between the anterior leaf and underlying loose connective tissue. Both scissor tips are directed upward to be seen through the peritoneum as they advance. Gentle opening and closing of scissor blade tips during advancement separates the peritoneum from the underlying connective tissue. The tented anterior leaf is then incised sharply. The line of incision curves inferiorly and medially to the level of the vesicouterine fold, which generally lies just below the uterine isthmus (Fig. 43-12.3).

Next, to further open the retroperitoneal space, the drape of peritoneum lying between the round ligament and infundibulopelvic (IP) ligament is grasped with smooth forceps and placed on tension. This peritoneum is incised with Metzenbaum scissors and with the same undermining technique used for the anterior leaf (Fig. 43-12.4). Lateral and parallel to the IP, the incision is extended cephalad toward the pelvic sidewall.

Ureter Identification

This is accomplished by localized blunt dissection that is advanced downward with gentle cephalad and caudad strokes into gauzy retroperitoneal tissue above the presumed ureter path (Fig. 43-12.5). Dissection is directed downward, medially, and slightly cephalad toward the medial aspect of the posterior peritoneal leaf, along which the ureter courses. Small vessels are coagulated as they are found.

Posterior Broad Ligament Leaf

With the ureter directly visualized, the posterior peritoneal leaf is incised to create a window. If ovarian preservation is planned, this window is made beneath the uteroovarian ligament alone. If oophorectomy is planned, the posterior leaf of the broad ligament is incised parallel to the IP ligament. The incision is extended toward the pelvic brim and medially toward the uterus just below the uteroovarian ligament. This delineates the IP for ligation (Fig. 43-12.6).

Adnexectomy

If the adnexa are to be removed, the fallopian tube and ovary are grasped with a Babcock clamp and elevated medially to place the IP ligament on mild tension for improved delineation (Fig. 43-12.7). With the ureter visualized, a curved Heaney clamp can be placed around this ligament with its arc curving upward. The tips of the clamps are placed through the previously created peritoneal window. A Kelly clamp is placed medial to this and closer to the adnexa.

With clamps secured, the IP ligament is sharply transected above the Heaney clamp. A free tie of 0-gauge delayed-absorbable suture is placed around the Heaney clamp. As the knot of this suture is secured, the Heaney clamp is quickly opened and closed, that is, “flashed.” A transfixing stitch is then sutured below the clamp but above and distal to the first free tie. As the knot is cinched, the Heaney clamp is removed.

The adnexa is now freed from the pelvic sidewall, and its increased mobility may obstruct the surgeon’s view. Accordingly, the adnexa can be tied to the Kelly clamp still located on the cornu. Alternatively, adnexa can be simply excised and removed.

Ovarian Conservation

With the leaves of the broad ligament now open, if the ovary is to be preserved, then salpingectomy alone is now completed. This is fully described in Section 43-8. In summary, the mesosalpinx is serially clamped, cut, and ligated. Each clamp incorporates approximately 2 cm of mesosalpinx, and resection progresses from the fimbria to its union with the uterus.

To preserve the ovary, one Kelly clamp is already positioned at the cornu and across the uteroovarian ligament. A Heaney clamp is positioned lateral to this, and its arc faces the uterus (Fig. 43-12.8).

The intervening segment of uteroovarian ligament is incised between the Heaney and Kelly clamps. Ligation of the ligament is carried out as in Step 8. That is, a free tie of 0-gauge delayed-absorbable suture is placed around the Heaney clamp. As the knot is secured, the clamp is flashed. A transfixing stitch is then placed around the same clamp but distal to the first free tie. As the knot is cinched, the Heaney clamp is removed. The ovary is now freed from the uterus and can be placed laterally near the pelvic sidewall. The Kelly clamp is left in place at the cornu to prevent bleeding and allow uterine manipulation.

Bladder Flap

Steps 4 through 9 are completed bilaterally, and attention is next turned to the bladder. To avoid urinary tract injury, the bladder is moved caudad and away from the cervix. This is accomplished by first opening the vesicouterine space, the potential space between the bladder and cervix. Several techniques may be used, and at our institution, sharp dissection is preferred (Fig. 43-12.9). This method is particularly beneficial for patients with prior cesarean deliveries who may have scarring between the bladder and cervix. Alternatively, gentle blunt pressure from fingers or sponge stick can be used. Such pressure is directed beneath the bladder, against the cervix, and caudad. With either dissection method, taut uterine elevation creates helpful tension across the tissue planes to be separated. Tension is created by pulling upward on the Kelly clamps, previously placed at the cornua.

The peritoneum at the vesicouterine fold was previously incised bilaterally in Step 5. During dissection in the vesicouterine space, this peritoneum is grasped with atraumatic tissue forceps and elevated to create tension between it and the underlying cervix. Only loose connective tissue strands lie in this space, and they are easily cut with Metzenbaum scissors. Incision of these bands is kept close to the cervix to avoid cystotomy. Dissection in the midline minimizes laceration of vessels that course within the vesicocervical ligaments, colloquially termed bladder pillars. Once the correct plane is entered, the pearly white cervix and anterior vaginal wall are clearly differentiated from reddish bladder fibers.

The bladder is ideally dissected off the anterior vaginal wall at least 1 cm below the lower margin of the cervix. This averts incorporating bladder fibers within sutures or clamps placed during cuff closure. Thereby, bladder and distal ureteral injury, and later genitourinary fistulas, are prevented.

Uterine Arteries

The uterine artery and vein(s) are identified laterally along the uterus. At the level of the isthmus, some posterior peritoneum and loose areolar tissue still surrounds these vessels. Incising and removing such tissue from around any vessel is termed skeletonizing. This ultimately creates a smaller vascular pedicle and minimizes risks for vessel retraction during ligation.

To skeletonize, a surgeon individually grasps excess strips of perivascular connective tissue with fine smooth forceps and gently retracts them laterally and away from the uterine artery or vein. Metzenbaum scissors incise this tissue close to and parallel to the vessel, beginning superiorly and proceeding inferiorly. During this process, the remaining posterior broad ligament peritoneum is similarly incised parallel and close to the uterus (Fig. 43-12.10). Importantly, this step further “drops” the ureter away from the path of subsequent clamps.

Once skeletonized, the uterine vessels are clamped by a curved Heaney clamp at the uterine isthmus level. The clamp tips are placed horizontally across the vertical uterine vessels (Fig. 43-12.11). A Kelly clamp is placed medial and more vertical to the first clamp and hugs the lateral uterus to prevent bleeding from severed vessels. Tissue between the clamps is then cut.

A simple stitch of 0-gauge delayed-absorbable suture is placed below the Heaney clamp’s tip, and the suture ends are wrapped to the clamp’s heel. As the knot is cinched, the Heaney clamp is slowly opened and removed. The Kelly clamp remains.

Fundal Amputation

After bilateral uterine artery ligation, if the uterus is large and bulky, the uterine fundus may be sharply severed from the cervix. After removal of the corpus, Kocher clamps are placed on the anterior and posterior walls of cervix for manipulation.

If supracervical hysterectomy is planned, no further transection is required. In premenopausal women, the upper endocervical canal is coagulated or removed by wedge resection to help avoid postoperative cyclic bleeding. The cervical stump is closed and rendered hemostatic with figure-of-eight stitches using 0-gauge delayed-absorbable suture. Each stitch passes through the posterior peritoneum, the posterior wall of the cervix, and then the anterior wall of the cervix before ligation. Conversely, if the cervical stroma is hemostatic, no suturing may be required.

Cardinal and Uterosacral Ligament Transection

These ligaments lie lateral to the uterus and inferior to the uterine vessels. A straight Heaney clamp is positioned across the cardinal ligament adjacent to the cervix and medial to the uterine artery pedicle (Fig. 43-12.12). As the Heaney clamp initially grasps the ligament, it is oriented parallel to the lateral side of the uterus. As the clamp is slowly closed, it is angled slightly away from the vertical axis of the cervix. A scalpel is used to transect the portion of the cardinal ligament medial to the clamp. A transfixing stitch of 0-gauge delayed-absorbable suture is placed below the clamp, and the clamp is removed as the knot is cinched. For smaller bites through the cardinal ligament, a simple stitch without transfixion may suffice.

Depending on the ligament length, the above step may be repeated several times. In this manner, the cardinal ligament is transected and ligated from its superior to inferior extent down the lateral aspect of the cervix to the level of the upper vagina. When this is near completion, the uterosacral ligaments remain as final support structures attached to the cervix. These ligaments are more easily felt and seen by placing upward traction on the uterus. In most benign cases, these ligaments are incorporated within instruments used to clamp across the lower cardinal ligament and proximal vagina.

Vagina Transection

For this step, the surgeon’s hand palpates through the anterior and posterior vaginal walls to identify the most inferior level of the cervix. Here, a curved Heaney clamp incorporates the uterosacral ligament and is placed across the anterior and posterior vaginal walls just below the cervix on one side. This is repeated on the other side, and the tips often meet in the midline (Fig. 43-12.13). Importantly, the bladder must be sufficiently mobilized away from this point to prevent injury.

The vaginal tissue above the level of these clamps is then transected. This procedure frees the uterus from the pelvis. Transfixing sutures are placed below the Heaney clamps, and the clamps are removed (Fig. 43-12.14).

Vaginal Entry

During some cases, the cervix may be poorly appreciated between the vaginal walls. To avoid shortening the vagina or leaving cervix behind, the vagina can be entered to identify the cervix. For this, a small longitudinal incision is made in the midline of the upper anterior vaginal wall. A finger is inserted to palpate the cervical margin. Once this level is known, one blade of Jorgensen scissors is inserted into the vagina and positioned just below the cervix (Fig. 43-12.15). At this level, the vagina is then circumferentially cut. Kocher or Allis clamps are placed along the free cut vaginal edge as it forms.

Vaginal Cuff Closure

For support, a 0-gauge delayed-absorbable suture may be placed to suspend the vaginal apex to the uterosacral ligament pedicle on either side (Fig. 43-12.16). This stitch incorporates the anterior and posterior vaginal walls with the distal portion of the uterosacral ligament and helps prevent vaginal cuff prolapse following surgery.

These sutures are kept long and held by hemostats. Upward and lateral traction elevates the vaginal cuff. The full thicknesses of the incised anterior and posterior vaginal walls are then reapproximated with a running suture line using 0-gauge delayed-absorbable suture or with several figure-of-eight sutures. The peritoneum overlying the posterior vaginal margin should be included in this closure to lessen the risk of postoperative oozing. Anteriorly, the bladder should be kept clear of the suture line. Once the vaginal cuff is hemostatic, the lateral suspending cuff sutures are cut.

Wound Closure

The abdominal incision is closed as described in Section 43-1 or 43-2.

POSTOPERATIVE

Postoperative care follows that for laparotomy, although sexual intercourse is usually delayed until 6 weeks after surgery to permit satisfactory vaginal cuff healing.

Febrile morbidity is common following abdominal hysterectomy and exceeds that seen with vaginal or laparoscopic approaches (Peipert, 2004). Frequently, fever is unexplained. But, pelvic infections are common, and other sources of postoperative fever should be evaluated (Chap. 42). Because of the high rate of unexplained fever, which resolves spontaneously, observation for 24 to 48 hours for mild temperature elevations is reasonable. Alternatively, antibiotic treatment may be initiated, and appropriate choices are found in Table 3-20. Additional testing, including transvaginal sonography or computed tomography (CT), may be indicated if a pelvic hematoma or abscess is suspected.

In general, this approach is chosen by surgeons if the uterus is relatively small, extensive adhesions are not anticipated, no significant adnexal pathology is expected, and some degree of pelvic organ descent is present. Compared with abdominal hysterectomy, patients undergoing vaginal hysterectomy usually benefit from faster recovery and from reduced hospital stays, costs, and postoperative pain. During selection of hysterectomy approach described on page 950, if all factors are equal, then vaginal hysterectomy is preferred.

PREOPERATIVE

Patient evaluation, consenting, and patient preparation are similar to that for abdominal hysterectomy.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

After adequate general or regional anesthesia is administered, the patient is placed in standard dorsal lithotomy position (Fig. 40-4). The vagina is surgically prepared, and the bladder is drained. Some surgeons may prefer to wait until the anterior peritoneum is entered before inserting a Foley catheter. This permits a gush of urine to signal inadvertent bladder laceration. Along the posterior vaginal wall, a short Auvard weighted vaginal speculum is placed, and a right-angle or other suitable retractor is placed anteriorly.

Vaginal Wall Incision

To begin, one Lahey-thyroid clamp is used to grasp the anterior cervical lip, while a second one holds the posterior lip. For a smaller cervix, one clamp may easily grasp both lips together. The junction between the cervix and the anterior and posterior vaginal walls can be seen and palpated by in-and-out displacement of the cervix. Just proximal to this junction, a circumferential incision is made around the cervix and is guided by anatomy (Fig. 43-13.1). For example, if the cervix is flush with the vagina, then incision lies close to the remaining cervix to avoid rectal injury. In general, the incision is kept at a depth superficial to the cervical stroma to avert dissection into the cervix. To minimize blood loss during dissection, 10 to 15 mL of a dilute saline solution containing vasopressin (20 U diluted in 30–100 mL of saline) or 0.5-percent lidocaine and epinephrine (1:200,000 dilution) may be injected circumferentially along the incision path.

Posterior Entry

Although described first here, the sequence of anterior and posterior entry is based on surgeon preference and intraoperative findings. The Lahey-thyroid clamp and cervix are lifted anteriorly to expose the posterior vaginal vault, and an Allis clamp is placed below the circumcised edge of the posterior vaginal wall. Downward traction on the Allis clamp creates tension across the incision. Curved Mayo scissors positioned across the incision line cut to enter the cul-de-sac of Douglas (Fig. 43-13.2). The posterior peritoneum may be affixed centrally to the posterior vaginal wall incision with a single stitch of delayed-absorbable suture. This approximation will assist with closure of the peritoneum at the procedure’s end. The short Auvard speculum is replaced by one with a longer blade, which enters the cul-de-sac.

Anterior Peritoneal Entry

This is generally considered the most challenging step of vaginal hysterectomy. First, the anterior vaginal wall is grasped near the circumferential incision in the midline and elevated with an Allis clamp. Tension is concurrently created by outward traction on the cervical Lahey-thyroid clamps. This traction reveals fibrous connective tissue bands connecting the bladder and cervix. These bands fill the vesicocervical space, which is typically 3 cm long (Balgobin, unpublished data). Although the proximal part of this space contains loose areolar tissue, the distal portion contains thicker fibers. This knowledge permits calm, persistent dissection through this dense tissue rather than prematurely reorienting dissection, which risks “digging” into the cervix.

At our institution, sharp dissection is preferred (Fig. 43-13.3). This method is particularly beneficial for patients with prior cesarean deliveries, who may have scarring between the bladder and cervix. With traction established, the fibers are incised in the midline with Metzenbaum scissors. Tips are kept close and almost parallel to the cervix as dissection is extended cephalad. Bleeding vessels are frequently encountered during initial dissection and are coagulated. After the initial fibers are transected, gentle palpation with the index finger should indicate whether the upper part of the vesicocervical space has been reached. In the absence of scar tissue, these fibers are easily broken, and gentle blunt dissection is advanced cephalad until the vesicouterine fold is palpated. Alternatively, the entire vesicocervical space dissection can be completed with gentle blunt pressure from an index finger covered in surgical gauze. Such pressure is directed against the cervix and cephalad toward the vesicouterine fold.

This fold is a thin and transparent transverse peritoneal fold at the upper border of the cervix. With palpation, this smooth layer glides against the uterine serosa. This peritoneum is grasped with atraumatic tissue forceps, placed on tension, and incised (see Fig. 43-13.3). In cases with difficult anterior entry, the surgeon may enter the posterior cul-de-sac and wrap an index finger anteriorly to palpate and accentuate the vesicouterine fold for anterior entry.

Following vesicouterine fold incision, an index finger explores the opening to confirm peritoneal entry, exclude cystotomy, and identify unanticipated pelvic pathology. This finger then guides a curved Deaver retractor into the opening to elevate the bladder and anterior vaginal wall.

Transection of Uterosacral and Cardinal Ligaments

Outward traction on the Lahey-thyroid clamps pulls the supporting uterine ligaments into view. Such traction, along with upward bladder displacement, helps prevent ureteral injury. The uterosacral and cardinal ligaments are identified, clamped with a curved Heaney clamp, transected, and ligated with 0-gauge delayed-absorbable suture using a transfixing stitch (Fig. 43-13.4). Once the knot of this pedicle is tied, the suture ends are not cut but kept long for later identification. This step is then repeated on the opposite side.

Depending on the cardinal ligament length, similar clamping, cutting, and suturing may need to be repeated. Advancement is cephalad, and along each side and parallel to the cervix. Each sequential clamp is placed medial to the prior pedicle to reduce ureteral injury risk.

Uterine Arteries

The uterine artery is identified on one side and clamped with a curved Heaney clamp. The clamp is placed nearly perpendicular to the long axis of the uterus and medial to the prior cardinal ligament pedicle (Fig. 43-13.5). The tips should firmly abut the uterus to ensure enclosure of entire artery and vein(s) within the clamp. A more laterally placed clamp may not be completely enclose the artery. Following pedicle transection, a simple stitch is placed around the clamp and is secured at the clamp heel as the instrument is removed. Uterine arteries are ligated bilaterally.

Cornua

Progressing cephalad, curved Heaney clamps are next placed across the round and uteroovarian ligaments and fallopian tube (Fig. 43-13.6). After transection, a simple stitch of 0-gauge delayed-absorbable suture is placed proximally around the clamp. As the knot is secured, the Heaney clamp is quickly flashed. A transfixing stitch is then sutured around the clamp and positioned distal to the first stitch. As this knot is cinched, the Heaney clamp is removed. This transection is repeated bilaterally. With ovarian preservation, these sutures are cut short after confirming pedicle hemostasis. However, for adnexectomy, the transfixing suture tails may be kept long to allow gentle traction to bring the adnexa toward the vagina.

For the above step, if the uterus is larger, the uteroovarian ligament and tube may be difficult to reach and clamp. For this, the uterine corpus may be delivered through the posterior colpotomy incision to better expose these. To deliver the fundus, a tenaculum is placed on the upper posterior uterine wall, and it gently pulls the fundus into the vagina. Excessive traction may result in tissue avulsion and bleeding. Conversely, if the uterus is small and descent is adequate, the uteroovarian and round ligaments and fallopian tube may be combined together in one curved Heaney clamp (Fig. 43-13.7). The pedicle is doubly ligated with a simple suture first placed proximally and then with a transfixing stitch placed distally.

With ovarian preservation, some recommend consideration of bilateral salpingectomy to lower high-grade peritoneal and ovarian serous carcinoma rates. However, during vaginal hysterectomy, complete resection of the tube is typically more challenging than during abdominal approaches, and iatrogenic bleeding may lead to oophorectomy or conversion to laparotomy. If tube removal is desired, then adjunctive laparoscopic salpingectomy may be considered to ease safe removal of the entire tube.

Morcellation

In some cases, the uterine fundus may be too large to deliver, and uterine debulking is required prior to ligation of the cornual attachments. This is performed only after both uterine artery pedicles have been secured.

One technique bisects the uterus using curved Mayo scissors, beginning at the cervix and moving toward the fundus. Near completion, fingers placed through the anterior colpotomy incision and behind the fundus help prevent scissor injury to adjacent organs (Fig. 43-13.8). Once completed, one half is elevated out of the operating field and into the pelvic cavity, whereas the other is brought into view for clamp placement across the uteroovarian and round ligaments and fallopian tube (Fig. 43-13.9). Other methods either enucleate individual large leiomyomas or involve cervix-to-fundus central coring to remove volume (Fig. 43-13.10). Once bulk is diminished, a Heaney clamp may be placed around the cornual structures as described in Step 7.

Adnexectomy

For this, the adnexa is grasped with a Babcock clamp and gently pulled inferiorly and toward the contralateral side of the incision. This creates mild tension on the infundibulopelvic (IP) ligament for improved delineation. To expand the operating field, a right-angle or similar retractor is positioned deep into the incision for vaginal sidewall retraction. This is coupled with upward traction from the originally placed anterior wall retractor.

A curved Heaney clamp is placed around the IP ligament, and its blades cover the entire pedicle width. For difficult angles, the surgeon’s contralateral hand can push the ligament into correct position within the clamp. Prior to clamp closure, the surgeon confirms that no bowel or omentum is incorporated and that the entire ovary lies distal to the clamp. A moist sponge stick and slight Trendelenburg positioning can push the bowel away from the operative field.

The IP ligament is then clamped and transected (Fig. 43-13.11). First, a free tie of 0-gauge delayed-absorbable suture is placed around the Heaney clamp. As the knot is secured, the clamp is flashed. A transfixing stitch is then placed around the same clamp but distal to the first free tie. As the knot is cinched, the Heaney clamp is removed. Excess traction on this pedicle is avoided to prevent avulsion or retraction of the ligament from the clamp. In such cases, resultant retroperitoneal bleeding may be difficult to control vaginally. Once hemostasis is ensured, the suture is cut. The opposite IP ligament is similarly clamped and transected.

Evaluation of Hemostasis

Following removal of the uterus, the surgical pedicles are inspected for bleeding. Electrosurgical coagulation or figure-of-eight sutures will typically control bleeding from discrete points. If indicated or preferred, a McCall culdoplasty may be performed (Section 45-22).

Vaginal Cuff Closure

The anterior and posterior vaginal walls are usually reapproximated by a horizontal suture line with interrupted or continuous running stitches of 0-gauge delayed-absorbable material. If short vaginal length is a concern, walls can be closed by a vertical suture line.

To help prevent later vaginal apex prolapse, the uterosacral ligament pedicles are incorporated within the cuff closure. For this, the interrupted or continuous running closure suture is initially passed through the anterior vaginal wall, through the ligament, through the posterior peritoneum, and finally through the posterior vaginal wall on one side (Fig. 43-13.12). This is repeated on the other side. Suturing then progresses from each side to the midline, or a single running suture may close the entire cuff line. During cuff closure, full thickness bites through the vaginal wall are taken. Also, the posterior peritoneum is incorporated with the closure to minimize risks of bleeding and cuff hematoma.

POSTOPERATIVE

In general, patients who undergo vaginal hysterectomy compared with abdominal hysterectomy, typically have faster return of normal bowel function, easier ambulation, and decreased analgesia requirements. Although diet and most activities are advanced quickly, intercourse is delayed for 6 weeks to permit vaginal cuff healing. Evaluation and treatment of postoperative complications mirrors that for abdominal hysterectomy.

For many women who have had supracervical hysterectomy, later surgical removal of the cervix, termed trachelectomy, is often indicated for complaints of vault prolapse, persistent cyclic bleeding, or preinvasive cervical lesions (Pasley, 1988). Hilger and associates (2005) reported on 335 women who underwent trachelectomy between 1974 and 2003. In half of them, trachelectomy was performed, on average, 26 years after supracervical hysterectomy. Of surgical indications, prolapse and pelvic mass are the most frequent. Bleeding accounts for nearly 10 percent of cases (Hilger, 2005; Kho, 2011).

The cervix may be removed either vaginally or abdominally, but for most women without concurrent pelvic pathology, vaginal trachelectomy is preferred (Pratt, 1976). With the resurgence of supracervical hysterectomy, now performed via laparoscopy, rates of trachelectomy for benign causes may rise.

Trachelectomy for benign indications is described here. Radical trachelectomy for invasive cervical cancer is gaining acceptance and is described in Chapter 30.

PREOPERATIVE

Patient Evaluation

As with hysterectomy, women require preoperative Pap test screening to exclude cervical cancer. Microscopic examination of cervicovaginal secretions will identify infections that merit treatment before surgery.

Consent

As with vaginal hysterectomy, patients are at risk for urinary tract and bowel injury. Similarly, postsurgical vaginal cuff complications may include hematoma, abscess, and cellulitis. Fortunately, complications are infrequent for most. Although Pratt and Jeffries (1976) noted complications in 91 of 262 patients, complication rates in several series range below 10 percent (Riva, 1961; Welch, 1959).

Patient Preparation

Entry into the peritoneal cavity is common during trachelectomy. Accordingly, as with vaginal hysterectomy, prophylaxis against postoperative infection and venous thromboembolism is warranted. Appropriate choices are found in Tables 39-6 and 39-8. Enemas the evening prior to surgery aid in evacuation of the rectum.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Trachelectomy is performed as an inpatient procedure under general or regional anesthesia. The patient is placed in a standard dorsal lithotomy position, the vagina is surgically prepared, and a Foley catheter is placed.

Incision and Extraperitoneal Dis­section

The beginning steps of trachelectomy mirror those for vaginal hysterectomy (Step 2). However, unlike vaginal hysterectomy, because the cervical stump lies outside the peritoneum, entry into the peritoneal cavity is not required for trachelectomy. Accordingly, once circumcision of the vaginal wall around the cervix is completed, dissection proceeds to the vesicouterine fold but without peritoneal entry.

In many cases, the bladder is more densely adhered to the anterior cervix, and the clear tissue planes often encountered during vaginal hysterectomy are absent. Moreover, if at completion of the original hysterectomy, the peritoneum was reapproximated to cover the cervical stump, then the bladder may be draped over and scarred to the apex of the stump as well. For this reason, dissection of the vaginal wall, bladder, and rectum from the surface of the cervix typically requires sharp rather than blunt dissection (Fig. 43-14.1). As with vaginal hysterectomy, outward traction on the cervix in combination with counter traction of the vaginal wall aids dissection. To avoid cystotomy and proctotomy, scissor blades and dissecting pressure are directed against the cervix.

Transection of Uterosacral and Cardinal Ligaments

Once dissected free from the vaginal wall, the uterosacral and cardinal ligaments are clamped and ligated as with vaginal hysterectomy (Fig. 43-14.2). The cervical branches of the uterine artery are typically clamped and ligated with the cardinal ligament. Depending on cervical length, serial transection and ligation of the cardinal ligament is continued cephalad until the stump apex is reached.

Stump Excision and Cuff Closure

Once the apex is reached, sharp dissection across the top of the stump will free it from the vagina (Fig. 43-14.3). Next, incorporation of the uterosacral ligaments and reapproximation of the vaginal walls follows that for vaginal hysterectomy (Step 11).

POSTOPERATIVE

As with hysterectomy, a significant number of women will have unexplained febrile morbidity following trachelectomy. Pasley (1988) in his series of 55 cases noted a rate of 9 percent. Similar to hysterectomy, patients with persistent or high-degree fevers require evaluation and possible antibiotic treatment (Chap. 42).

This procedure is a primary tool for diagnostic evaluation and treatment of abnormal uterine bleeding. However, the indications for dilatation and sharp curettage (D & C) have decreased with the development of less invasive methods such as plastic endometrial samplers and transvaginal sonography (Chap. 8).

For evaluation of abnormal uterine bleeding, sharp curettage may be used alone or more commonly in combination with hysteroscopy for those women with persistent bleeding despite normal findings with sonography and endometrial biopsy. In some, mechanical cervical dilatation followed by curettage may be required to gain access to the uterine cavity when a stenotic cervical os prohibits in-office endometrial sampling. Also, if uterine malignancy is suspected and initial biopsy is incomplete, D & C may permit a more thorough removal and interrogation of endometrial tissue.

In the treatment of severe acute menorrhagia, D & C may be used to remove hypertrophic endometrium if bleeding must be stopped promptly or if bleeding is refractory to medical management. Although suction curettage is used more commonly for removal of first-trimester pregnancy products, sharp D & C may also be an option (Chap. 6). Finally, in women with suspected ectopic pregnancy, D & C sometimes is used to document the absence of intrauterine trophoblastic tissue (Chap. 7).

PREOPERATIVE

Consent

For most women, sharp dilatation and curettage poses only a small risk of complication, and rates are typically below 1 percent (Radman, 1963; Tabata, 2001). Infection and uterine perforation are among the most frequent. With uterine perforation, concern for adjacent organ injury may require diagnostic laparoscopy or laparotomy and injury repair. Although rare, the possibility of hysterectomy is also discussed.

Patient Preparation

Because the indications for sharp D & C are diverse, diagnostic testing prior to evacuation will vary. Sonography is a frequent evaluation tool, and images are reviewed preoperatively to reorient the surgeon to uterine inclination and pathology.

Prophylactic antibiotic administration is typically not required when sharp D & C is performed for gynecologic indications. However, because pelvic infection may follow this procedure when performed in an obstetric setting, antibiotics are usually prescribed postoperatively. Doxycycline, 100 mg orally twice daily for 10 days, is a frequent choice (American College of Obstetricians and Gynecologists, 2014a). The risk of bowel injury or venous thromboembolism (VTE) with this procedure is rare. Thus, preoperative enema or VTE prophylaxis in those without additional risk factors is not mandatory.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Dilatation and curettage is typically performed as an outpatient procedure under general or regional anesthesia or with local nerve blockade combined with intravenous sedation. The patient is placed in standard dorsal lithotomy position, the vagina is surgically prepared, and the bladder drained.

A bimanual examination to determine uterine size and inclination is performed prior to introduction of vaginal instruments. Information obtained from this examination helps avoid uterine perforation. With insertion of instruments along the long axis of the uterus, there is less chance of injury.

Uterine Sounding

Suitable vaginal exposure can be achieved with either a Graves speculum or individual vaginal retractors. The anterior lip of the cervix is grasped with a single-tooth tenaculum to stabilize the uterus during dilatation and curettage. A Sims uterine sound is then held like a pencil with the thumb and first two fingers (Fig. 43-15.1). The sound is slowly guided through the cervical os, into the uterine cavity, and to the fundus. To minimize perforation risks, instruments are not forced and are kept in the midline.

Once gentle resistance is met at the fundus, the distance from the fundus to the external os is measured by score marks along the length of the sound. Knowledge of the depth to which dilators and curettes can safely be inserted also decreases perforation risk.

At times, cervical stenosis may preclude easy access to the endocervical canal. In these cases, smaller caliber tools, such as a lacrimal duct probe, can be guided into the external cervical os to define the canal path. Sonography may be helpful when done simultaneously with D & C in these situations. Sonographic visualization of instruments as they are being passed may help assure proper placement (Christianson, 2008). In addition, pretreatment with the prostaglandin E₁ analogue misoprostol (Cytotec) may allow adequate cervical softening for instrument passage. Commonly used dosing options include 200 or 400 μg vaginally or 400 μg orally or sublingually once 12 to 24 hours prior to surgery. Song and coworkers (2014) noted equal efficacy but a patient preference for oral administration. Common side effects include cramping, uterine bleeding, or nausea.

Uterine Dilatation

After the uterus is sounded, dilators of sequentially increasing caliber are inserted to open the endocervical canal and internal cervical os. A Hegar, Hank, or Pratt dilator, as shown on page 967, is held by the thumb and first two fingers, while the fourth and fifth fingers and heel of the hand rest on the perineum and buttock. Each dilator is gently and gradually advanced through the internal cervical os. Serial dilatation continues until the cervix will admit the selected curette (Fig. 43-15.2).

During sounding or dilatation, uterine perforation may occur and is suspected when the instrument travels deeper than previously measured. Because of the blunt, narrow shape of these tools, risk of significant uterine or abdominal organ injury is low. In such cases, if significant bleeding is absent, reassessment of uterine inclination and completion of the D & C is reasonable. Alternatively, surgery may be terminated and repeated at a later date to allow myometrial healing. Importantly, lateral perforation may create a broad ligament hematoma, which if suspected merits laparoscopic evaluation or postoperative surveillance of hemodynamic status.

Uterine Curettage

Prior to curettage, a sheet of nonadherent wound dressing material (Telfa pad) is spread out in the vagina beneath the cervix. The uterine curette is then inserted and advanced to the fundus, following the long axis of the corpus. The concave curve of the curette loop has a sharp edge, which allows curettage. On reaching the fundus, the sharp surface is positioned to contact the adjacent endometrium (Fig. 43-15.3). Pressure is exerted against the endometrium as the curette is pulled toward the internal cervical os.

After reaching the os, the curette is redirected to the fundus and positioned immediately adjacent to the path of the first curettage pass. After several passes, tissue accumulated in the isthmic region is scraped out onto the Telfa pad. In this fashion, the entire uterine cavity is sequentially and circumferentially curetted. The collected specimen is sent for pathologic evaluation.

As with dilatation, the uterus may be perforated during curettage. In contrast to the metal sound or dilator, the sharp curette has the potential to lacerate bowel, vessels, and other abdominal organs. Accordingly, diagnostic laparoscopy is considered to evaluate for such injuries.

Uterine Exploration

Uterine polyps, both large and small, may be missed with sharp curettage. As described in Chapter 8, hysteroscopy is a more accurate means to diagnose and remove focal lesions and is often coupled with D & C. In areas without these resources or expertise, uterine exploration with Randall kidney stone forceps can be used to secure and remove polyps. For this, closed forceps are inserted into the endometrial cavity. Upon reaching the fundus, forceps are opened against the uterine walls, closed, and then pulled away from the endometrium. With this technique, anterior, posterior, proximal, and distal cavity surfaces are explored. With capture of a polyp within the jaws, a tug against the closed forceps is felt as they are pulled away from the uterine wall. Firm traction typically frees the polyp. Removed tissue is sent for pathologic evaluation.

POSTOPERATIVE

Recovery from sharp D & C is typically fast and without complication. Light bleeding or spotting is expected, and patients may resume normal activities at their own pace.

Suction dilatation and curettage (D & C) is the most frequently used method to remove first-trimester products of conception. Vacuum aspiration, the most common form of suction curettage, requires a rigid plastic cannula attached to an electric-powered vacuum source. Alternatively, manual vacuum aspiration uses a similar cannula that attaches to a handheld syringe for its vacuum source (Lichtenburg, 2013).

PREOPERATIVE

Patient Evaluation

For most women, dilatation and curettage is preceded by transvaginal sonography. As discussed in Chapter 6, this imaging modality aids in documenting pregnancy nonviability, location, and size as well as uterine inclination. Images are reviewed preoperatively to reorient the surgeon to this information. In addition, complete blood count and blood typing results are reviewed. For women with significant preoperative bleeding, resuscitation as described in Chapter 40 is completed. Most molar pregnancies are treated with evacuation, and special preparation is described in Chapter 37. For Rh-negative women, administration of anti-D immune globulin intramuscularly within 72 hours of pregnancy termination can lower the risk of alloimmunization in future pregnancies. Doses of 300 µg (1500 IU) can be given for all gestational ages. Alternatively, dosing may be graduated, with 50 µg given IM for pregnancies ≤12 weeks and 300 µg given for those ≥13 weeks.

Consent

Suction D & C is a safe and effective method of uterine evacuation (Tunçalp, 2010). Short-term complication rates are low and have been cited at 1 to 5 percent (Hakim-Elahi, 1990; Zhou, 2002). Complications include uterine perforation, retained products, infection, and hemorrhage, and rates increase after the first trimester. Accordingly, sharp or suction curettage is ideally performed before 14 to 15 weeks’ gestation.

The incidence of uterine perforation associated with uterine evacuation varies. Important determinants are surgeon skill, uterine position, and uterine size. Rates of perforation increase with a retroverted or large uterus and with a less experienced surgeon. Accidental uterine perforation usually is recognized when the instrument passes without resistance deep into the pelvis. Observation may be sufficient if the uterine perforation is small, as when produced by a uterine sound or narrow blunt dilator. Considerable intraabdominal damage, however, can be caused by instruments—especially suction cannulas and sharp curettes—passed through a uterine defect into the peritoneal cavity. Because unrecognized bowel injury can cause severe peritonitis and sepsis, laparoscopy or laparotomy to examine the abdominal contents is often the safest course of action in these cases.

Rarely, women may develop cervical incompetence or intrauterine adhesions following D & C. Those undergoing this procedure should understand the potential for these rare but significant complications.

Patient Preparation

Suction D & C may be performed for cases of incomplete or inevitable abortion and require no cervical dilatation for procedure completion. However, other settings require physical dilatation of the cervical os with metal dilators, a procedural step closely associated with uterine perforation and patient discomfort. Therefore, to obviate this need, hygroscopic dilators may be placed in the endocervical canal to the level of the internal os. These dilators draw water from cervical proteoglycan complexes, which dissociate and thereby allow the cervix to soften and dilate.

Two dilator types are currently available in the United States. One type originates from the stems of Laminaria digitata or Laminaria japonica, a seaweed. The stems are cut, peeled, shaped, dried, sterilized, and packaged according to their hydrated size—small, 3 to 5 mm diameter; medium, 6 to 8 mm; and large, 8 to 10 mm (Fig. 43-16.1). Another type, Dilapan-S, is an acrylic-based hydrogel rod.

For dilator placement, the cervix is cleansed with povidone-iodine or similar solution and grasped anteriorly with a tenaculum. A laminaria of appropriate size is then inserted using a uterine packing forceps so that the tip rests at the level of the internal os (Fig. 43-16.2). After 4 to 6 hours, the laminaria will have swollen to dilate the cervix sufficiently and allow easier D & C. Cramping frequently accompanies expansion of the device.

In addition to mechanical tools, various prostaglandin preparations have been investigated as cervical “ripening” agents. Misoprostol has been used effectively to induce uterine evacuation in properly selected patients. However, studies investigating its preoperative use to ease cervical dilatation prior to pregnancy evacuation show inconsistent results (Mittal, 2011; Sharma, 2005). Moreover, in comparison, laminaria prove more effective than misoprostol for ripening (Burnett, 2005; Firouzabadi, 2011).

Antibiotic prophylaxis is provided at the time of transcervical surgical pregnancy evacuation. Based on review of 11 randomized trials, Sawaya and associates (1996) concluded that perioperative antibiotics decreased the infection risk by 40 percent. Although no regimen appears superior, a convenient, inexpensive, and effective one is doxycycline, 100 mg orally twice daily for 10 days. Table 39-6 lists alternatives.

INTRAOPERATIVE

Instruments

Suction D & C requires an electric suction unit; stiff, translucent, large-bore sterile suction tubing; and sterile Karman suction cannulas (Fig. 43-16.3). Plastic suction cannulas are available in varying diameters. They also have a straight or slightly bent shaft, which can be select to conform to uterine cavity inclination. Choosing the most appropriately sized cannula balances competing factors. Small cannulas risk postoperative retention of intrauterine tissue, whereas large cannulas risk cervical injury and greater discomfort. For most first-trimester evacuations, a no. 8 to 12 Karman cannula is sufficient.

Surgical Steps

Anesthesia and Patient Positioning

In the absence of maternal systemic disease, abortion procedures do not require hospitalization. When abortion is performed outside a hospital setting, capabilities for cardiopulmonary resuscitation and for immediate transfer to a hospital must be available. Anesthesia or analgesia used varies and includes general anesthesia, paracervical block plus intravenous sedation, or intravenous sedation alone. After delivery of anesthesia or analgesia, the patient is placed in standard dorsal lithotomy position. Bimanual examination to determine uterine size and inclination is performed prior to introduction of vaginal instruments. Information obtained from this examination helps avoid uterine perforation. The vulva and vagina are then surgically prepared, and the bladder is drained.

Uterine Sounding and Cervical Dilatation

A Graves speculum or other suitable vaginal retractor(s) is positioned in the vagina to allow cervical access. A single-tooth tenaculum is placed on the cervical lip to provide gentle countertension during instrument passage. First, a Sims uterine sound (Fig. 43-15.1) is placed through the cervical os and into the uterine cavity to measure the depth and inclination of the uterine cavity prior to dilatation.

If the cervix is closed or incompletely dilated, metal Pratt, Hegar, or Hank dilators (Fig. 43-16.4) of sequentially increasing diameter are placed through the external and internal os to gently open the cervix. The uterus is especially vulnerable to perforation during this step. Accordingly, the metal dilator is grasped as one would a pencil. The heel of the hand and fourth and fifth fingers rest on the perineum and buttock. Gentle pressure from only the thumb and first two fingers is used to push the dilator through the cervical os (Fig. 43-16.5).

Uterine Evacuation

Through the now opened cervix, the Karman cannula is inserted into the endometrial cavity (Fig. 43-16.6). The suction unit is then turned on. The cannula is moved toward the fundus, then back toward the os, and is slowly turned circumferentially to cover the entire surface of the uterine cavity (Fig. 43-16.7). A gush of clear fluid into the tubing often heralds entry of the cannula into the gestational sac. This collapses the sac and draws the placenta and membranes closer to the cannula for more expedient removal. Uterine contents are thereby removed (Fig. 43-16.8).

Tissue is collected in an attached container at the distal end of the tubing and is sent for pathologic evaluation. Occasionally, the Karman cannula may become obstructed with excess tissue. For this, the suction unit is turned off prior to cannula removal. Once the cannula opening is cleared of obstructing tissue, it may be reinserted, suction reestablished, and curettage completed.

Sharp Curettage

Although no more tissue is aspirated, a gentle sharp curettage is often completed to remove remaining placental or fetal fragments (Fig. 43-16.9). This is fully described in Section 43-15.

POSTOPERATIVE

Recovery from suction D & C is typically fast and without complication. Patients may resume normal activities as they desire, but abstinence from coitus is usually encouraged during the first week following surgery. Ovulation may resume as early as 2 weeks after an early pregnancy ends. Therefore, if contraception is desired, methods are initiated soon after abortion.

Imperforate hymen results from failure of the hymen to canalize during the perinatal period. Following menarche, menstrual blood accumulates behind this vaginal obstruction. Distention of the vagina and uterus with blood are hematocolpos and hematometra, respectively. For this reason, many cases are diagnosed after patients have become symptomatic, usually during adolescence. Accordingly, the indications for hymenectomy may include complaints of amenorrhea, pain, abdominal mass, and urinary and defecation dysfunction (Chap. 18).

An asymptomatic imperforate hymen may also be found early, during childhood. If there is no associated mucocele, lesions can be managed expectantly. Elective hymenectomy can then be performed during puberty, when tissues are estrogenized, but prior to menarche to avoid hematometra or hematocolpos. The presence of estrogen aids surgical repair and healing.

PREOPERATIVE

Consent

Hymenectomy is a simple gynecologic procedure, and most patients recover with no short- or long-term complications. Uncommonly, the hymeneal edges may reepithelialize, and a repeat procedure may be required (Liang, 2003).

Patient Preparation

Bowel preparation and antibiotic or venous thromboembolism prophylaxis are not required for this brief surgery.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Hymenectomy is typically performed as a day surgery procedure using general anesthesia. The patient is placed in standard dorsal lithotomy position, the bladder is drained, and a sterile perineal prep is performed.

Hymen Incision

To avert injury to the urethra anteriorly and to the rectum posteriorly, the surgeon avoids creating pure vertical and horizontal incisions. Instead, a cruciate incision is made anteroposteriorly from 10 to 4 and from 2 to 8 o’clock into the hymeneal membrane (Fig. 43-17.1). Immediately, a stream of dark menstrual blood in the case of hematocolpos or mucoid fluid with mucocolpos will follow. The hymeneal leaflets are then sharply trimmed from the hymeneal ring. These are not excised too closely to the vaginal epithelium to avoid increased scarring at the hymeneal ring.

Irrigation

The vagina is copiously irrigated using a sterile saline solution with either a red rubber catheter or bulb syringe. Intraoperative evaluation or manipulation of the upper vagina, cervix, and uterus is discouraged, as the walls of these organs may have been greatly thinned by hematocolpos or hematometra and are at risk for perforation.

Suturing

The cut edges of the leaflet bases are then oversewn with interrupted stitches using 3-0 or 4-0 gauge delayed-absorbable suture, thus creating a ring of sutures (Fig. 43-17.2). A running interlocking suture line is avoided to minimize circumferential narrowing of the introitus.

Some use an alternative to sharp trimming and suturing of the leaflets. Instead, hemostats are placed across each leaflet base for approximately a minute to crush and seal fine vessels. After clamp removal, an incision with electrosurgical blade or scissors is carried through the crush line, excises distal leaflet tissue, and eliminates the need for suturing.

POSTOPERATIVE

Following surgery, the patient may use oral analgesics and topical anesthetics such as lidocaine ointment. Local wound care includes twice-daily sitz baths. The patient is counseled that retained fluid may continue to drain from the uterus and vagina for several days following the procedure. The patient is seen 1 to 2 weeks following surgery, at which time the introitus is inspected for patency and assessment of healing.

Bartholin gland duct cysts and abscesses are vulvar masses encountered routinely in office gynecology (Chap. 4). Bartholin duct cysts typically measure 1 to 4 cm in diameter and are frequently asymptomatic. Patients with larger cysts, however, may complain of vaginal pressure or dyspareunia. In contrast, patients with gland duct abscesses typically complain of rapid unilateral vulvar enlargement and significant pain. Classically, a fluctuant mass is found on one side of the introitus, external to the hymenal ring, and at the lower aspects of the vulva.

Bartholin cysts or abscesses result from ductal opening obstruction followed by accumulation of mucus or pus within the gland duct. Bartholin gland abscesses are polymicrobial infections, and Bacteroides species, Peptostreptococcus species, Escherichia coli, and Neisseria gonorrhoeae are frequently found from culture of purulent drainage. Less typically, Chlamydia trachomatis may be involved (Bleker, 1990; Kessous, 2013).

Incision and drainage (I & D) alone may give immediate but sometimes only temporary relief. Often, unless a new duct ostium is created, the incised edges following I & D will seal and mucus or pus will reaccumulate. Therefore, I & D with subsequent steps to create a new ostium are surgical goals.

Permanent resolution of the cyst or abscess is the norm following either marsupialization or I & D with Word catheter placement. However, if obstruction recurs, repeating either of these procedures is preferable to gland excision for most cases. Bartholinectomy, described on page 975, carries significantly greater morbidity than either of these two less invasive procedures.

PREOPERATIVE

Consent

Repeated obstruction of the Bartholin gland duct following initial incision and drainage (I & D) is not uncommon during the weeks and months following drainage. Patients are informed of the possible need to repeat the procedure should the duct obstruct again. Dyspareunia is an infrequent long-term sequela, but patients are counseled regarding this potential. Rarely, deep tissue infection or rectovaginal fistula may develop postoperatively.

INTRAOPERATIVE

Instruments

The goal of Bartholin gland duct I & D is to empty the cystic cavity and create a new accessory epithelialized tract for gland drainage. For the latter, a Word catheter is used (Word, 1964). This is constructed of a 1-inch-long latex tube stem that has an inflatable balloon at one end and a saline-injection hub at the other (Fig. 43-18.1).

Surgical Steps

Analgesia and Patient Positioning

Most procedures are performed as an outpatient procedure in the office or emergency room. Rarely, if the abscess is large or if adequate patient analgesia cannot be obtained, then I & D in the operative room may be required. The patient is placed in standard dorsal lithotomy position, and the ipsilateral labial skin is cleaned with a povidone-iodine solution or other suitable antiseptic agent. Local analgesia is sufficient for most cases and can be obtained by infiltrating the skin overlying and adjacent to the planned incision with an aqueous 1-percent lidocaine solution. This may be augmented with mild intramuscular or intravenous analgesia.

Drainage

A 1-cm incision is made using a scalpel with a no. 11 blade to pierce the skin and underlying cyst or abscess wall (Fig. 43-18.2). The incision is made atop the cyst, is placed just outside and parallel to the hymen at 5 or 7 o’clock (depending on the side involved), and is positioned medial to Hart line. This position mimics the normal anatomy of the gland duct opening and avoids creation of a fistulous tract to the outer labium majus (Hill, 1998). To minimize scalpel injury, some recommend use of a small Keyes punch biopsy to instead create a hole simultaneously through the skin and cyst wall.

General bacterial culture as well as samples specific for Neisseria gonorrhoeae and Chlamydia trachomatis identification can be obtained from spontaneously extruded pus. Mucus drained from a Bartholin cyst need not be cultured. Following drainage, the cavity is explored with a small cotton swab tip to open potential pus or mucus loculations. Probing is gentle to avoid perforation through the duct wall and into the nearby and highly vascular vestibular bulb (Fig. 38-26). Cyst wall biopsy following cavity drainage to exclude rare Bartholin gland carcinoma is considered for women older than 40 years, for cysts with solid components, or for multiple cyst recurrences.

Word Catheter Placement

A deflated Word catheter tip is placed into the empty cyst cavity. A syringe is used to inject 2 to 3 mL of sterile saline through the catheter hub to inflate the balloon. Inflation should reach a diameter sufficient to keep the catheter from falling out of the incision (Fig. 43-18.3). Alternatively, a nonlatex 14F Foley catheter is a suitable substitute for those with latex allergy or in settings without a Word catheter. In either case, insufflation with saline rather than air is preferred, as the latter is associated with premature balloon deflation. The hub end of the Word catheter can then be tucked inside the vagina to prevent it from being dislodged by traction from normal perineal movement.

POSTOPERATIVE

Bartholin gland duct cyst drainage does not require antibiotic treatment. In contrast, abscesses are typically surrounded by significant cellulitis, and in such cases, antibiotics are warranted. Suitable choices include trimethoprim-sulfamethoxazole (Bactrim DS, Septra DS), doxycycline, or cephalexin (Keflex), prescribed for 7 to 10 days. At our institution, affected immunocompromised women are admitted for intravenous antibiotic therapy until fever or erythema improves.

Patients are encouraged to soak in warm tub baths twice daily. Coitus is avoided for patient comfort and to prevent Word catheter displacement. Ideally, the catheter is left in place for 4 to 6 weeks. Often, however, a catheter will be dislodged before this time. There is no need to try and replace the catheter if displaced, and attempts to reinsert it are typically not possible due to cavity closure.

As noted earlier, a new duct ostium must be created following I & D of a Bartholin duct abscess to prevent the incised edges from adhering and allowing pus to reaccumulate. For this reason, marsupialization was developed as a means to create a new accessory tract for gland drainage.

With introduction of the Word catheter, however, use of marsupialization for cyst or abscess has declined. Word catheter placement offers several advantages over marsupialization, and recurrence rates are equal (Blakely, 1966; Jacobson, 1960). Marsupialization requires a greater degree of analgesia, a larger incision, placement of sutures, and longer procedure time. That said, this procedure may be selected for those with large abscesses or cysts, those with recurrences after Word catheter failures, or those with latex allergy.

PREOPERATIVE

Consent

The patient consenting discussion for marsupialization mirrors that for Bartholin gland duct I & D. Thus, patients are informed of possible abscess or cyst recurrence. Uncommon postoperative complications are dyspareunia, deep tissue infection, or rectovaginal fistula.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Marsupialization is an outpatient procedure typically performed in an operating suite using a unilateral pudendal nerve block or general anesthesia. Some authors, however, have described performance of the procedure in an emergency room setting (Downs, 1989). The patient is placed in standard dorsal lithotomy position, and the vulva and vagina are surgically prepared.

Skin Incision

A vertical or elliptical incision measuring 2 cm is made across the skin overlying the cystic bulge using a scalpel with either a no. 10 or 15 blade. The incision is made atop the cyst, is placed just outside and parallel to the hymen at 5 or 7 o’clock (depending on the side involved), and is positioned medial to Hart line. This position mimics the normal gland duct opening anatomy and avoids creation of a fistulous tract to the outer labium majus (Fig. 43-19.1).

Cyst Incision

A second vertical incision then opens the underlying cyst wall, and pus or mucus under pressure spills out. Pus may be cultured as described on page 971. Allis clamps are then placed on the superior, inferior, right, and left lateral cyst wall edges and fanned out.

Following drainage, the cavity is explored with a small cotton swab tip to open potential fluid loculations. Probing is gentle to avoid perforation through the duct wall and into the nearby and highly vascular vestibular bulb (Fig. 38-26). In addition, cyst wall biopsy following cavity drainage to exclude rare Bartholin gland adenocarcinoma is considered if the patient is older than 40 years or if solid components accompany the cyst.

Wound Closure

The edges of the cyst wall are sutured to adjacent skin edges with interrupted sutures using 2-0 or 3-0 gauge delayed-absorbable suture (Fig. 43-19.2).